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Full text of "United States Navy Medical News Letter Vol. 45 No. 5, 12 March 1965"

NAVMED P-5088 




Vol. 45 



Friday, 12 March 1965 



No. 5 




CONTENTS 



Admiral Kenney's Message to 
SUBMARINE MEDICINE 

35 Medical Officers Graduate from School of 
Submarine Medicine 

Project Argus: The Neuropsychiatry Effectiveness 
of Future Naval Weapons System Crews 

ORIGINAL ARTICLES 

Prevention and Treatment of Heat Casualties in 

Mojave Desert 

Medical Frontier 

FROM THE NOTE BOOK. 

Limited Duty Recommendations by Boards of 

Medical Survey 

Your Will 

Army PG Short Courses for Medical Department 
Officers 

Oak Knoll Conducts Children's Preventive Dental 
Health Program 

Surgeon General Asks for Maximum Support of 
SecNav Task Force by Medical Department 

DENTAL SECTION 

Excerpts from Report by American Academy of 
Restorative Dentistry 



All Hands 

DENTAL SECTION (Cont'd) 



12 
12 

13 

13 

13 

14 



Pulp Health During Complete Coverage Procedures 16 

Topical Use of Prednisolone in Periodontics 17 

Personnel and Professional Notes 17 

PREVENTIVE MEDICINE 

Tuberculosis Control in the Navy — Are We Doing 

Enough? 18 

A State of Apathy? . 22 

Symposium on Venereal Disease 22 

Early Detection of Phenylketonuria 22 

Know Your World 23 

MISCELLANY 

BUMED Instruction 6222.9 24 

American Industrial Hygiene Conference to Con- 
vene in Houston, Texas 24 

Group Discussion Reduces Accident Rates 24 

Mr. J. R. Berkshire Appointed to American Psycho- 
logical Assn. Committee 25 

Second Annual Rocky Mountain Bio-engineering 

Symposium 25 

Measles Vaccination Advised 25 



Vol. 45 



United States Navy 
MEDICAL NEWS LETTER 



Friday, 12 March 1965 



Rear Admiral Robert B. Brown MC USN 
Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 
William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine CDR J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine CDR J. H. Schulte MC USN 



No. 5 



Policy 

The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be. nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new 
addresses. 



FRONT COVER: Aerial view of the U.S. Naval Hospital, Annapolis, Maryland (Official U.S. Navy Photograph). 
The first structure at the U.S. Naval Academy to be used as a hospital was a small, four room wooden building 
constructed in 1846 "on the plain (parade grounds below the Superintendent's House, near the old mulberry 
tree". The second hospital, of three stories, was near the present Officers' Club. It was occupied from 1857 to 
1871. The third hospital, erected on a plateau overlooking the Severn River was occupied in 1871 and closed 
in 1876. The site was too near the swamps along the river and the incidence of malaria was so high among the 
patients and staff that the hospital was closed from 1876 to 1907. at which time the fourth and present hospital 
was constructed and occupied. 

The improved hospital facilities of today are largely the result of major permanent construction in 1939 
and 1941. In 1939: T'iree story West Ward Building, housing Wards 9 and 10, Operating Room, X-Ray De- 
partment, EEN&T Clinic, Surgical Dressing Rooms, Physiotherapy Department, and a Personnel Records Office. 
In 1941: New three story East Ward Building containing two large wards, a Dependents' Ward and Clinic, Labor 
and Delivery Rooms, Nursery, Dental Office, Medical Storerooms, Finance Office and Morgue. Also, in 1941, 
there were built modern quarters for Nurse Corps Officers and Hospital Corpsmen, and a subsistence building, 
housing the Food Service Department, Auditorium and Library. — Editor. 

The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 

U.S. NAVY MEDICAL NEWS LETTER 



ADMIRAL KENNEY'S MESSAGE 
TO ALL HANDS 

PRIOR TO HIS RETIREMENT AS SURGEON GENERAL, REAR ADMIRAL 
E. C. KENNEY FORWARDED THE FOLLOWING LETTER TO ALL MEDICAL 
ACTIVITIES UNDER THE MILITARY COMMAND OF THE CHIEF, BUREAU 
OF MEDICINE AND SURGERY. SINCE THE SENTIMENTS EXPRESSED IN 
THIS LETTER APPLY TO ALL PERSONNEL OF THE NAVY MEDICAL 
DEPARTMENT WHOSE ENERGIES AND LOYAL SUPPORT MADE POSSIBLE 
THE ACCOMPLISHMENTS DURING HIS APPOINTMENT, ADMIRAL KENNEY 
DESIRED THAT THIS LETTER BE PUBLISHED IN THE MEDICAL NEWS 
LETTER : 

"Rather than meditate on my impending retirement on 1 March, I would much rather reflect on the accom- 
plishments of the Navy Medical Department during my term as Surgeon General. This has been modest in some 
areas and quite substantial in others. Regardless of the degree, it is a tribute to the selfless dedication, the enduring 
energy, the faithful cooperation and loyal support of that superb group of officers, enlisted men and civilians which 
constitute the personnel of the Medical Department. 

It is true that we require adequate funds, suitable facilities, modern equipment and ample drugs and supplies 
to complement our professional skills but, in the end, it is the intelligent use of these inert objects in the practice 
of our profession which fulfills our mission to the Navy. 

Our business is providing a service to the Navy. We relieve suffering and restore health whenever possible. 
Our service is very personal in its nature and, not infrequently, is provided during periods of emotional stress or 
crisis. This only serves to increase our responsibility to succeed since our results are so vital to the individual and 
to his or her loved ones. 

During these past four years our personnel allowances in all corps have 'ncreased; our allotment of funds 
has grown; training and education have expanded; new facilities have been constructed with particular attention 
to out-patient clinic spaces and intensive care areas for the hospitalized patient as part of a progressive care 
concept; rapid medical augmentation of our ships of the fleet and marine forces has been planned and success- 
fully tested under emergency conditions; an increased awareness has stimulated bio-medical research in the life- 
sciences and life-support systems', preventive dentistry has received major attention; our medical Reserve programs 
have been reoriented and, hopefully, strengthened; and our stature in the healing arts has increased. 

I doubt if there has been any other period when the Congress, the Secretary of the Navy, the Chief of 
Naval Operations, and others in positions of authority have had more interest and sincere concern regarding the 
health and well-being of the serviceman and his family. The support we have received in our bio-medical research 
and patient-care areas has been superb in every instance where we could present an intelligent and realistic 
requirement. All this occurred during a time when many other programs and new weapons systems were vigor- 
ously competing for recognition and support. The equitable apportionment of assets available to the Navy is a 
thing which would challenge the wisdom of a Solomon but I do believe we have received a reasonable share. 
This might logically be questioned by the staff in some of our major treatment facilities where the demand for 
professional services almost overwhelms their capability but I believe sincere reflection will reveal the gains we 
have made. 

I am confident that my eminently capable successor, Rear Admiral Robert B. Brown, will provide a superb 
quality of leadership and direction. Talented educator, skillful surgeon and capable administrator, he will bring 
his varied talents to the task of projecting Navy medicine to greater heights. 

I am deeply conscious of the opportunity that has been mine to play a part in this medical drama of service 
to our great Navy and I want to sincerely thank you and all those persons whose professional skill and tireless 
energy have made my task more pleasant and rewarding. 

I wish to extend to you and all my colleagues and associates my sincere gratitude and a hearty "Well Done." 



(?}r. 



E. C. KENNEY 
U.S. NAVY MEDICAL NEWS LETTER 




SUBMARINE MEDICINE SECTION 




SCHOOL OF SUBMARINE MEDICINE GRADUATES 
CLASS OF THIRTY-FIVE MEDICAL OFFICERS 



On 19 December 1964, thirty-five medical officers 
graduated from the School of Submarine. Medicine, a 
department of the U.S. Naval Submarine Medical Cen- 
ter, Submarine Base New London, Groton, Conn. 

CAPT Robert C. Gillette USN, delivered the com- 
mencement address. CAPT Gillette is Commander of 
Submarine Flotilla TWO and Submarine Squadron 
TWO. He was introduced by CDR A. Dalton James 
MC USN, Director of the School of Submarine Medi- 
cine. Diplomas were presented by CAPT Charles L. 
Waite MC USN, Commanding Officer of the Submarine 
Medical Center. 

The honor man of the class was LT Robert N. 
Sawyer MC USN, who received the Surgeon General's 
award in absentia, since an operational assignment with 
the Blue Crew of USS Sam Houston required LT Saw- 
yer's departure prior to graduation. Six other members , 
of the class graduated with distinction: LT Robert 
Crafts Jr., LT Thomas A. Gehring, LCDR Walter F. 
Miner, LT Robert M. Moore, LT John P. Smith, and 
LT Neal E. Winn,— all of the Medical Corps. LT Saw- 
yer came into the Navy upon receiving his MD degree 
from Western Reserve Medical School, Cleveland, Ohio, 
in 1963. He served his internship at the U.S. Naval 
Hospital, Oakland, California. 

During the 22 week course of instruction in the New 
London School, prospective submarine medical officers 
are fully oriented and prepared for duty in submarine 
and diving billets. Phases of diving medicine, submarine 
medicine, respiratory physiology, mathematics, nuclear 
physics, radiobiology, radiation and atmosphere control 
aboard submarines, and basic line officers' submarine 
training, are among the subjects covered by the School. 

Although the School's staff prepares the curriculum 
and qualified instructors are assigned to implement the 
course of instruction, guest lecturers are also obtained 
from other activities, including the Bureau of Medicine 
and Surgery, the Deep Sea Diving School, Naval Re- 
search Laboratory, Marine Engineering Laboratory, 



Brookhaven National Radiation Laboratories, Preven- 
tive Medicine Unit #2, and Yale Medical School. The 
Medical Center's Research Department and the Basic 
Officers' Submarine School at the New London Sub- 
marine Base provide additional assistance. 

Before the School of Submarine Medicine was estab- 
lished in New London, medical officers receiving diving 
training were formerly sent to the Deep Sea Diving 
School in Washington, D. C. To accomplish this type 
of training in New London, base and fleet facilities are 
utilized. "Hard Hat" diving instruction is given on 
board local submarine rescue ships while escape train- 
ing, pressure chamber indoctrination and SCUBA in- 
struction is conducted in the Submarine School's escape 
training tank. 

The last class of Prospective Submarine Medical 
Officers convened in February 1965. In addition to U.S. 
Navy doctors, six foreign Navy medical officers are 
attending this class. 

This class had several "firsts" in its record: It is the 
first to graduate under the auspices of the Submarine 
Medical Center, commissioned at the local base on 1 
July 1964; it is the largest class ever to graduate at the 
Submarine Base, it has the highest number of specialists 
in it — three internists, one pediatrician, and one radiol- 
ogist; it is the first class to receive its deep sea diving 
training on locally operating submarine rescue vessels; 
and it is the first class to include one Commander and 
three Lieutenant Commanders. 

Twenty-seven of the graduates were assigned to 
Polaris submarines. Of those remaining, two received 
orders to Submarine Squadron Staffs, and six were sent 
to nuclear reactor training. 

While on their initial assignment as Submarine Med- 
ical Officers, they may earn their "dolphins", thereby 
adding "qualified submariner" to their title. To accom- 
plish this, they must receive the recommendation of 
their commanding officer, publish a thesis pertaining to 



U.S. NAVY MEDICAL NEWS LETTER 



submarine or diving medicine, satisfactorily complete a 
comprehensive examination, and serve three months in 
a submarine or in a diving billet. 

Submarine Medicine is the military medical specialty 
which supports all underwater operations in the Navy. 



This includes providing medical services to the crews of 
all submarines, deep sea divers and underwater swim- 
mers. In general terms, the practice of submarine medi- 
cine can be considered a combination of general prac- 
tice and of occupational medicine. 



PROJECT ARGUS: 



THE NEUROPSYCHIATRY EFFECTIVENESS OF FUTURE 
NAVAL WEAPONS SYSTEM CREWS 



Forwarded to the Medical News Letter by CAPT John R. Seal MC USN, Commanding 
Officer, Naval Medical Research Institute, NNMC, Bethesda, Md. 20014. 



Operational requirements of naval weapons systems 
of the 1980's will include prolonged cruises of deeply 
submerged vehicles manned by small crews. Heavy 
psychiatric demands will be placed upon crew members, 
who must perform effectively under prolonged physical 
and geographical isolation, and in environments severely 
restricted as to amount and variety of social and sensory 
stimulation. 

Anticipating that such stress could generate emotional 
and social problems which would interfere with crew 
performance effectiveness, the Special Projects Office, 
BUWEPS requested and offered to fund a BUMED- 
managed research project which would provide means 
of assuring optimum neuropsychiatric effectiveness in 
crews of the planned weapons systems. Within 
BUMED, it was recognized that such research would be 
vital to fulfillment of its responsibilities to the fleet of 
the 1980's, and so this research challenge was accepted. 
It was also recognized that existing research programs 
in preventive and clinical psychiatry, neurology and 
psychophysiology, and adjustment to special environ- 
ments had necessarily been developed, staffed, and 
equipped with orientation to current needs of the fleet, 
and could not absorb the proposed research goals with- 
out detriment to ongoing work. It was clear, therefore, 
that a new research capacity would be required for the 
proposed program, and NMRI was selected as the logi- 
cal location for development of this capacity. 

At NMRI, establishment of the proposed program, 
short-titled "Project Argus," commenced in 1961 with 
a general definition of the required research effort, 
which was to be a five-to-ten year study of small groups 
in isolated, restricted environments, concentrated on: 
(a) crew composition and organization to maximize 
performance effectiveness; (b) identification of social 
and emotional factors producing crew disruption, and 
development of corrective measures; (c) refined cri- 
terion measures of crew effectiveness; and (d) tech- 
niques for minimizing the impact of stimulus-poor, 
isolated, and restricted environments on crew effective- 
ness. It was estimated that Project Argus would require 



an average of $300,000 per year for the initial five 
years, and the office of CNO provided a written com- 
mitment to provide such funds. 

During the next three years, Project Argus became 
fully operational. The current staff consists of one 
psychiatrist, nine Ph.D. investigators who represent 
social, clinical, and experimental psychology, and the 
personnel necessary for technical, administrative, and 
secretarial support. Physical facilities include: (a) six 
"deep isolation" laboratories which provide complete 
control over external visual and auditory stimulation, 
and which permit studies of small groups ranging in 
size from two to thirty, under conditions ranging from 
routine activities in isolation to virtual immobilization 
in darkness and silence; (b) four small group labora- 
tories equipped with one-way vision screens, communi- 
cations systems, and task equipment; (c) four multi- 
purpose laboratories equipped with closed-circuit TV 
as well as communications and task equipment. Defined 
by its mission, development, staff, and equipment, 
Project Argus is the only research effort within either 
DOD or NASA currently possessing the capacity for 
work in the problem areas described above. 

During the past year, activity under Project Argus 
has shown a marked shift from emphasis on staffing and 
instrumentation to active pursuit of research and analy- 
sis. The most extensive study completed was undertaken 
jointly by the Group Composition and Criterion 
branches. Its goal was to determine how the effects of 
isolation and confinement could be modified by group 
composition in terms of member personality traits: 
need for achievement, need for affiliation, need for 
dominance, and dogmatic styles of thought. It was 
found that certain pairs of men tolerated several days 
of isolation with relative ease, while others, particularly 
those in which both men were highly dominant, showed 
severe interpersonal conflict and were able to endure 
for less than ten days in isolation. Related efforts in the 
group composition area centered on individual styles of 
comparing one's self with others. The results indicate 
that these "social comparison" styles are important de- 



U.S. NAVY MEDICAL NEWS LETTER 



terminants of the stability of the individual's self- 
concept and, by inference, of individual psychiatric 
stability in small isolated groups. 

In the Group Processes Branch, major efforts cen- 
tered on the interaction of motivation, personality 
characteristics, and intelligence as determinants of task 
performance and response to social pressures. It was 
found that an individual's response, in both direction 
and degree, to motivational manipulations is affected by 
his intellect and personality; in particular, one individual 
type characterized by marked deterioration in per- 
formance under conditions of increased reward, was 
identified. 

The activities in the Environmental Restructuring 
Branch centered mainly on instrumentation of the deep 
isolation laboratories. Considerable progress was made 
also in developing collaborative studies of the effects of 
monotony in isolation, in identifying measures of an 
individual's isolation tolerance, and in development and 
validation of measures of subjective stress and emotional 
symptomatology in isolation. 

During the year, much progress was made in estab- 
lishing effective liaison with the Naval Medical Neuro- 
psychiatric Research Unit in San Diego, with Project 
SEALAB, and with other civilian laboratories in the 
U.S. and Canada where sensory deprivation and social 
isolation research is conducted. Further, Project Argus 
staff personnel actively participated in a Summer Study 
Session at the Naval Postgraduate School, Monterey 
under sponsorship of the Polaris ad hoc Group, with 
the mission of defining requirements for a 20-year re- 



search and development program for the Navy's 
achievement of a deep-ocean capability. 

During the remainder of FY 65, the bulk of research 
will progress along lines indicated by results to date, 
and as guided by the basic conceptual framework of 
Project Argus which relates events of the "personnel 
subsystems" to ultimate criteria of effectiveness and 
cost. The first studies using the deep isolation labora- 
tories are planned for early CY 65. 

In subsequent years, improvement in Project Argus' 
capability along neurophysiological and psychopharma- 
cological lines is planned. Many of the behavioral 
responses occurring under isolation and confinement 
appear associated with, or derived from, physiological 
changes which can and should be measured and inte- 
grated with psychological changes. On the basis of such 
knowledge, it appears likely that psychopharmacological 
means of facilitating small crew performance effective- 
ness in isolation could be researched and developed. 

NOTE: Trained submarine medical officers pro- 
vide advice, guidance, and consultation to the staff 
of Project Argus. When adequately trained and 
experienced, and if sufficiently interested, qualified 
submarine medical officers can be assigned to duty 
in this or similar research billets. If you desire 
further information regarding the Submarine Medi- 
cine Program, address inquiries to CDR John H. 
SCHULTE MC USN, Director, Submarine and 
Radiation Medicine Division, Bureau of Medicine 
and Surgery, Navy Department, 2300 E. Street, 
N. W., Washington, D. C. 20390.— Editor 



ORIGINAL ARTICLES 



PREVENTION AND TREATMENT OF HEAT CASUALTIES 
IN THE MOJAVE DESERT 

CDR B. G. Clarke MC USNR (Ret). Assistant Professor of Urology, Northwestern 
University Medical School; Urologist, St. Francis Hospital, Peoria, Illinois." 1 



A study was made of heat casualties among Marine 
Corps Reservists occurring during three-day field exer- 
cises held during the second week of Annual Field 
Training during the summers of 1962, 1963 and 1964 
at the Marine Corps Base, Twentynine Palms, Cali- 
fornia. During the 1962 exercise heat casualties severe 
enough in the judgement of umpires, unit leaders or 
unit corpsmen to require evacuation occurred at the 
rate of 37 per 1000 men per day, In 1963 the rate was 
5.2 and in 1964, 2.4 per 1000. 

In retrospective analysis of possible causes for dimin- 
ished losses in training time in 1963 and 1964 it 



appeared that in these years there had been intensive, 
preliminary training of troops in the proper use of 
water and salt in the desert. In staff planning the supply 
and distribution of water and salt were stressed as a 
paramount responsibility of command at all levels. 

Based on the datum that a man, walking at 3.5 mph 
in air with temperature of 110 degrees F., will lose a 
quart and a half or a canteen and a half of sweat every 
hour (1), containing about 0.2% of salt, a minimum 
planning factor for drinking water was set at 3 gallons 

* A reserve officer on Annual Field Training in 1963 and 1964 as 
senior medical officer, USMCR Desert Field Exercises 1-63 and 1-64 
at Twentynine Palms, Calif. 



U.S. NAVY MEDICAL NEWS LETTER 



per day per man and troops were instructed to consume 
six salt tablets a day in addition to salting their food 
heavily. They were trained to carry two canteens, to 
refill them as often as possible, and to drink from them 
freely and often even if they were not thirsty. Natural 
thirst can be shown { I ) to cause men under these con- 
ditions to drink only two thirds of the water they need 
in order to maintain maximum combat efficiency. 

The 1963 and 1964 exercises supported findings in 
previous experiments (3, 4) that physical conditioning, 
combined with acclimatization, cuts down the rate of 
heat casualties. A total of 22 had to be evacuated in 
1963 and 5 in 1964. None of these occurred among 
simulated enemy troops who had spent the preceding 
first week of Annual Field Training performing vigorous 
reconnaissance on foot throughout a large area of hilly 
desert. The simulated friendly forces, among whom all 
the heat casualties occurred, had spent the week before 
the exercise undergoing training in circumscribed local- 
ities on level ground with plenty of motor transport. 

Natural acclimatization, well recognized as influenc- 
ing the incidence of heat casualties (5, 6) probably was 
the cause of the difference in incidence of heat casualties 
between 1963 and 1964. In 1963, the Reservists came 
from New England and the Lake States. The rate of 
evacuation was 5.2 per 1000 per day. In 1964, when 
most of the Reservists were from either Louisiana or 
Utah, the rate was 2.4. 

Among a majority of victims who were questioned, a 
history of previous shortage of water, salt, food or all 
three could be elicited. 

At battalion aid stations or the field hospital, treat- 
ment consisted of rapid evaluation, rapid rehydration 
and gentle but rapid cooling. To accomplish the latter, 
men were undressed and put in the current of electric 
fans or in air conditioned mobile dental or surgical 



operating rooms and cool moist cloths were applied to 
their bodies. Sudden application of ice or ice-cold 
cloths appeared to cause severe discomfort and agita- 
tion. 

Rehydration by intravenous infusion of normal saline 
solution under the supervision of medical officers was 
accompanied by rapid recovery in all cases treated in 
1963 and 1964. In the absence of professional super- 
vision or under conditions of shortage of intravenous 
fluids, it is believed that satisfactory treatment of de- 
hydration might consist of oral administration of large 
amounts of pre-salted (0.1%) water and other bev- 
erages, cooled if possible. This contains about half the 
salt content of unacclimatized sweat, but cannot be 
tasted and does not cause gastric irritation (2). 

Experience in these three desert field exercises ap- 
peared to confirm the findings of previous observers 
( 1 ) that "man's chief concern in the desert is to have 
available as much water as he needs to replace all that 
he evaporates as sweat" and that natural thirst leads 
men under these conditions to drink only about two 
thirds of the water they need. Acclimatization appeared 
to reduce the incidence of heat casualties and the effect 
of acclimatization seemed to be enhanced by simul- 
taneous physical conditioning. The applicability of ad- 
vice contained in Marine Corps Order 6200. 1A(7) was 
again shown. 

REFERENCES 

1. Adolph, E. F. et a!: Physiology of Man in the Desert. New York, 
Interscience Publishers, 1947. 

2. Adam, J. M., Major, RAMC: Personal communication 1964. 

3. Bass, D. E., et al: Mechanisms of Acclimatization to Heat in 
Man. Medicine, 1955, 34: 323. 

4. Army Operational Establishment Reports 12/63 and 14/63 (Great 
Britain). 

5. Army Personnel Research Committee Project P.21 (Great Britain). 
British Medical Research Council. 

6. Army Personnel Research Committee Report 61/31, 1961 (Great 
Britain) British Medical Research Council. 

7. Marine Corps Order 6200.1 A, Prevention of Heat Casualties. 



MEDICAL FRONTIER* 

Louis E. Adams HM1 USN, Laboratory Department, Station Hospital, Navy #214, FPO, New York, N. Y. 



Americans go abroad as tourists or as members of the 
Armed Forces to return home, in most cases, with a 
maturity and concern they had not previously possessed. 
Many of our people leave for other countries not fully 
aware that they are acting as ambassadors in presenting 
our way of life to other people of the world. Often they 
are exposed to a mode of life considerably different 
from their own, but not necessarily better or worse. 
Only through humility, knowledge, and understanding 
of what exists in the non-American world can Amer- 
icans hope to attain a climate of mutual respect. 

As eager travelers preparing an itinerary for our few 
precious weeks or possibly months abroad, we gather 
all sorts of information about the climate, the best 



restaurants, and the most beautiful and exotic places of 
interest. This information is usually available in travel 
folders and brochures, but sometimes it is supplemented 
by a friend who has already made the trip. Despite our 
adroitness in making our plans, we seldom look into the 
problem of disease prevalance and sanitary conditions 
other than making sure that our basic immunizations 
meet the requirements. People who have little or no 
knowledge of the medical standards and requirements 



* The writer takes this opportunity to acknowledge his indebtedness 
to Joseph F. Britton LCDR MC USN, for unfailing aid, counsel, 
and encouragement through the preceding year. Thanks are also 
due to Arthur King CDR MSC USN, and Joseph R. Baranski 
HMCS USN, of Preventive Medicine Unit #7, Naples, Italy, for the 
confirmation of the bacteriological results presented in this paper. 



U.S. NAVY MEDICAL NEWS LETTER 



established by the Public Health Service of our own 
country may fail to realize that we are living in an en- 
vironment all our own, isolated by two oceans. Having 
received all of our shots, we leave America feeling 
quite safe. The toll from pneumonia, tuberculosis, in- 
fluenza, smallpox, typhoid, and other bacterial and viral 
diseases has been drastically reduced through enforced 
immunization procedures and usage of new drugs. This 
has been done to the extent that we forget these entities 
are a threat when we move from our relatively isolated 
and protected environment. 

This false sense of security was carried to the United 
States Naval Air Facility, Kenitra, Morocco by the vast 
majority of personnel. The knowledge of the health 
problems and sanitary conditions of the country could 
be obtained only after arrival. Even with the well pre- 
sented orientation lectures by the Medical Department 
Representative, a great number of people contracted 
gastrointestinal disorders. The following report is pre- 
sented to exemplify this problem. 

The chief complaints of hundreds of patients who 
reported to this Naval Air Facility seeking care were 
those of diarrhea, nausea and/or vomiting for the pre- 
ceding two or three days, accompanied by temperature 
ranging from 97 to 103 degrees Fahrenheit. In each 
case an examination was performed by a physician and 
a stool culture was obtained before starting the patient 
on chemotherapy. Initially, treatment varied with the 



physician. Some used tetracycline, others chlorampheni- 
col and sulfonamides with proper hydration. Specific 
antibiotic therapy appeared to give the best results. See 
Figure I, "In- Vitro Sensitivities of Enteric Pathogens." 
Some physicians, however, felt that symptomatic treat- 
ment might be best in the long run inasmuch as this 
perhaps offers an opportunity for the patient to develop 
a degree of immunity. 

Most patients responded very well to treatment and 
the clinical manifestations of the diseases disappeared 
after a period of 5 to 7 days. In the case of small chil- 
dren, dehydration and electrolyte imbalance were more 
critical and less tolerated than in the adult. Several 
children were hospitalized and one death occurred due 
to the loss of fluids through vomiting and chronic 
diarrhea, AH patients as well as station personnel were 
reminded of the health hazards of drinking the local 
water and eating improperly prepared food from restau- 
rants in the towns surrounding the Naval Air Facility 
and other areas in Morocco. 

In cases of diarrhea caused by Salmonella and Shigel- 
la, the enteric pathogens were initially present as the 
predominant organisms in the stool and as the symp- 
toms subsided the number of pathogens rapidly de- 
creased and were isolated with difficulty or not at all. 1 
Laboratory results of the rectal swabs and stool cultures 
are represented in figure 2. 



10 20 

ANTIBIOTICS TESTED 



30 



40 



50 



60 



70 



80 



90 100 



:-:u 



Chloromycitin 



^ 



m& 






Furoxone 



Furadantin 



Kanamyein 



Tetracycline 



m 



^j 



Erythromycin 



m 



M 



Gantrisin 



7? 



m 



Penici llin 



ii, 



Figure I. In-vitro sensitivities of enteric pathogens 



6 :-■ 



U.S. NAVY MEDICAL NEWS LETTER 



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1 1 1 1 1 1 1 1 1 



Aug Sept 



Oct 



Nov 



Dec 



Jan 



Feb 



Mar 



Apr 



May 



June 



July 



Figure 2. Laboratory results of rectal swabs and stool cultures (August I, 1962 — July 31,1963) 



SOURCES OF INFECTION 

Personnel reporting for duty at this military base 
frequently found that it was necessary to seek, housing 
for their families in the nearby towns and local com- 
munities in Morocco, due to the lack of sufficient hous- 
ing on the military compound. Living in the village of 
Kenitra or other local communities is fine for the 
"People to People" program and getting to know your 
Moroccan hosts, but one soon finds that the standards 
of personal hygiene and sanitation are extremely low 
and unacceptable to us. Animal and human defecation 
occurs in the streets, vacant lots, or nearby fields, at- 
tracting flies that harbor on foodstuffs which are gen- 
erally unprotected by screens. 

Most American families purchase fruits and veg- 
etables from the local market place, finding it difficult 
to resist their extraordinary quality in regard to size and 
flavor. These fruits and vegetables of course are con- 
taminated by the flies which are excellent vehicles for 
transmission of the Shigella and Salmonella organisms. 
The Moslem habit of "Ablution," washing the anus 
with water and using no toilet paper after every defeca- 
tion, plus the lack of soap and the sparse quantity of 
water used, makes direct finger contamination a likely 
cause of Shigella and Salmonella organisms on fruits 
and vegetables. It is therefore recommended that all 
produce be soaked in a chlorine type solution (two 



teaspoonfuls per one gallon of water) for 30 minutes 
to render it fit for consumption. 

Many animals are susceptible to Salmonella infections 
and thus act as a reservoir for this group of pathogens 
and the organisms may in turn be transferred to man. 

Eggs may become infected in the ovary or oviduct 
before the shell covering is added; or, penetration of 
the fresh intact shell covering by micro-organisms de- 
rived from feces, manure or soil, may occur. 1 Pasteur- 
ization of milk is not mandatory in Morocco and the 
consumption of non-pasteurized milk and milk products 
or eating other food that is contaminated due to im- 
proper handling is a common source of enteric path- 
ogens. 

The use of untreated, contaminated water for brush- 
ing teeth or for bathing small children is another means 
by which enteric infections are contracted. Even with 
close observation, small children can consume varying 
quantities of water while splashing about in the bathtub. 
It was recommended that only steaming hot water be 
drawn into the bathtub, allowing it to cool to the tem- 
perature that will permit the bathing of children. The 
enteric bacteria are killed by the temperature at which 
most domestic hot water heaters operate. 

Attention to the hygiene of breast feeding and the 
preparation and handling of food for small children is 
also very important. Cases of enteric diarrhea have 



U.S. NAVY MEDICAL NEWS LETTER 



been reported among patients in hospital wards. In ob- 
stetrical wards and nurseries this has been a major 
problem with newborn children "rooming in" with their 
mothers and acquiring what was first thought to be 
infantile viral diarrhea, but later proven to be caused 
by an enteric organism. In the NAF Station Hospital, 
Kenitra, Morocco, stool cultures are collected on all 
pregnant women upon admission to the obstetric wards 
in an attempt to anticipate the cross-contamination from 
mother to the newborn. 

The finding of enteric pathogens, when cultures were 
taken from the toys and play pens at the Base Nursery, 
necessitated advising all mothers not to leave their 
children in the Nursery, if a child had diarrhea or was 
under treatment for diarrhea. This was one of the 
preventive measures to control the communicable 
Shigellosis and Salmonellosis. 

Moroccan Nationals employed on the Base and en- 
gaged in work which brings them in direct contact with 
our personnel, for example, food handlers and barbers, 
were subjected to studies as possible carriers of the 
enteric pathogens. Thirty per cent were found to have 
both Shigella and Salmonella organisms present in their 
stool specimens. All were clinically asymptomatic. 
Unrelated, but of interest, approximately 22% were 
found to have positive serologies (VDRL)and 20% 
were found to have pathogenic ova and parasites in 
their stool specimens. 

WATER SUPPLY 

Water samples, collected off base from the water taps 
in homes of American families living in the town of 
Kenitra, were cultured in the Hospital Laboratory with 
the resultant isolation of enteric pathogens and coliform 
organisms. Surveys on the part of the Hospital's Sani- 
tation Department revealed that the water company 
chlorinated the water at the source. However, it is 
believed that the water became contaminated after leav- 
ing the plant. This is due to faulty piping arrangements 
beneath the streets and improper maintenance of the 
plumbing. Water distribution and sewage disposal pipes 
are installed side by side under the streets and waste 
material leaks from the sub-standard, mud filled joints 
of the sewage system water lines, thus contaminating 
the water. 

The use of water from the shallow surface wells lo- 
cated at the base of the slopes or hills was not recom- 
mended, since these wells are not covered to protect 
against contamination. Human and animal fecal ma- 
terial deposited on the hillsides above the wells is 
washed into the open wells when the "Seasonal Rains" 
begin. There are two seasons in Morocco: the first being 
the hot, dry summer and the second the rainy period. 
The increase of diarrheal diseases during the rainy peri- 
od is represented in Figure 2. 

As a matter of interest, rainfall during the period 
ending January 1963 caused the Sebou River to over- 
flow, resulting in the flooding of the area around 



Kenitra, Morocco, exceeding anything that had been 
experienced in many years. 

The Naval Air Facility's water supply is obtained 
from four deep wells located at the south end of the 
Air Facility. These wells are satisfactorily capped and 
sealed to insure protection from flooding and accidental 
contamination. The combined output of these wells is 
approximately 17,000,000 gallons of water per day. 

The raw water is delivered directly to the treatment 
plant where it is chlorinated by means of a mechanical 
gas chlorinator. The water is stored in an elevated 
reservoir or tank for use upon demand. 

BACTERIOLOGICAL ANALYSIS OF THE 
WATER, ICE, AND DAIRY PRODUCTS 

Water samples are routinely collected by medical 
department personnel each week from the outlets of the 
water distribution system for analysis of the bacterial 
content. 

A total of 237 water samples were collected from 1 
January 1963 through 30 September 1963. Thirty sam- 
ples were positive for enteric pathogens or coliform 
organisms. The majority of the sampling points giving 
positive results were at or near the two extreme ends 
of the water distribution system. Because of these find- 
ings, the chlorine content of the water supply was in- 
creased and a continuous flow procedure was initiated 
to allow the water containing an adequate amount of 
chlorine to reach the infrequently used outlets at the 
"dead ends" of the water system. Other positive water 
samples, collected from the outlets more frequently used 
and near the central section of the water system, were 
attributed to "outside spigot" contamination. The chlor- 
ine content of the water, simultaneously tested during 
the bacteriological collection, supports this conclusion, 
inasmuch as the chlorine residual was consistently with- 
in allowable limits. 

Each week a sample of ice from the ice plant was 
collected and submitted to the laboratory for deter- 
mination of the bacterial content. Shigella was isolated 
several times. This ice was used by personnel living 
aboard the station. In attempting to find the source of 
the contamination, a stool culture was obtained from 
the employee who operated the ice manufacturing plant. 
The results of the culture revealed that the worker did 
carry Shigella. The employee was removed from work 
at the ice plant and placed on antibiotic therapy. Fol- 
lowing treatment, repeated cultures were negative for 
Shigella and the employee was allowed to return to 
work. Bacterial analysis of the ice samples were nega- 
tive thereafter. 

COLLECTION OF WATER SAMPLES 

The water samples analyzed by the Hospital Labora- 
tory followed the procedures as outlined in Standard 
Methods.* 

* Standard Methods tor the Examination of Water, Sewage and In- 
dustrial Wastes, prepared by the United States Public Health 
Service. 



8 



U.S. NAVY MEDICAL NEWS LETTER 



The water is collected in a sterile bottle containing 
0.5 ml of 1.5% sodium thiosulfate. After collection of 
the water, the samples are taken to the laboratory and 
a 10 ml sample is aseptically inoculated into five large 
potato tubes of lactose broth. (Each tube contains an 
inverted Durham tube for the detection of gas forma- 
tion). The inoculated tubes are incubated at 35 degrees 
±0.5 degrees and examined at the end of 24±2 hours 
and again at the end of 48±3 hours and if gas has 
formed in the fermentation tube, this constitutes a posi- 
tive Presumptive Test. The absence of gas formation at 
the end of 48±3 hours incubation constitutes a negative 
test. 

Alt primary fermentation in the Presumptive Test 
showing any amount of gas at the end of 24 hours in- 
cubation is subject to the Confirmed Test. 

The Confirmed Test is done by transferring small 
portions by the use of a wire loop into a tube containing 
brilliant green lactose bile broth. The inoculated bril- 
liant green lactose bile broth is incubated for 48±3 
hours at 35 degrees ±0.5 degrees. The formation and 
presence of gas in any amount in the inverted Durham 
tube of the brilliant green lactose bile broth at any time 
within 48±3 hours constitutes a Confirmed Test. 

Samples containing growth and gas are subcultured 
on the media as outlined in the part of this writing 
entitled "Laboratory Procedure for Isolating Enterics." 

DAIRY PRODUCTS 
(SOURCE AND FINDINGS) 

Prior to August 1964, milk (recombined), cottage 
cheese, buttermilk and cream were purchased for sale 
in the commissary store and for use in the general mess, 
from the dairy plant in Casablanca. This plant, using 
dried fat-free milk and butter produced in the United 
States, manufactured the products mentioned. Ice 
cream, powdered milk, condensed milk, frozen milk, 
various cheeses, sherberts, and soft drinks produced in 
the United States, are also available in the commissary 
and are used in the general messes. 

Bacterial analysis of the U.S. manufactured products 
have shown them consistently free of pathogenic organ- 
isms and to conform to U.S. Public Health Service and 
federal specifications for such products. On the other 
hand, the milk and milk products from the Casablanca 
plant have shown the presence of Shigella and/or 
Salmonella on several occasions. Because of inability 
to produce a suitable product, the contract with the 
dairy in Casablanca was terminated. The bacteriological 
results reported in this paper have been confirmed by 
the bacteriology section of the U.S. Naval Medical 
School, NNMC, Bethesda, Maryland, and the bacteri- 
ological laboratory of the U.S. Navy Preventive Med- 
icine Unit #7, Naples, Italy. 



LABORATORY PROCEDURES FOR 
ISOLATING ENTERICS 

Basic differentiation of gram negative bacilli is a 
complex routine which requires strict adherence to 
established procedures and careful interpretation of the 
reactions. 

At this Station Hospital Laboratory cultures suspected 
of containing Shigella or Salmonella are inoculated in 
Selenite F medium, MacConkey's medium, Tetrathio- 
nate Broth, Salmonella and Shigella medium. 

After overnight incubation at 37 degrees C, the 
selected clear, colorless colonies are transferred to 
Kleigler's Iron Agar Slants by streak and stab. After 
incubation, those tubes showing alkaline slants and acid 
butts with or without gas and with or without Hydrogen 
Sulfide (HoS) productions, are transplanted to urea 
medium, Methyl Red-Voges Proskauer (MR-VP) medi- 
um, SIM medium, Nutrient agar, Citrate medium and 
fermentation tubes of glucose, lactose, sucrose, manni- 
tol, ducitol and salicin. The differentiation of the enteric 
organisms is accomplished as outlined in the Biochem- 
ical Chart for Enterics in Figure 3. 

SALMONELLA 

The Salmonella bacilli are gram negative, usually 
motile, non-encapsulated, nonsporing, nonpigmented 
rods. They are urease negative, methyl red positive, 
Voges Proskauer negative, indol negative, and usually 
Hydrogen Sulfide positive. All but S. typhi and S. 
gallinarum ferment glucose with the production of acid 
and gas. :l 

A potent endotoxin is liberated from these gram nega- 
tive bacilli when ingested by man. The organism or its 
toxins may enter the tissues through the intestine by way 
of the lymphatics, clinically presenting symptoms as 
fever, acute gastroenteritis, or a localizing type of in- 
fection in one or more organs, sometimes causing 
septicemia. 

Infection of the intestine is characterized in severe 
cases by frequent stools containing blood, mucus, and 
pus, and is accompanied by malaise, cramps, and mild 
fever. A positive blood culture is not uncommon during 
the first week of the infection. 

Salmonella bacilli may establish themselves in the 
tissues of the patient, producing a permanent carrier 
state after recovery from the acute infection. 

A small percentage of individuals, following recovery 
from a Salmonella infection, continue to carry the or- 
ganism in the intestinal tract, especially the gallbladder, 
for months or even for years. 4 

Transmission results from drinking water or milk 
contaminated by the Salmonella organism, eating food 
that has become contaminated by infected food handlers 
or insects such as cockroaches and flies. A person with 
a subclinical infection, "carrier", may contaminate food- 
stuff that is to be consumed. (See "Source of Infection" 
in writing.) 



U.S. NAVY MEDICAL NEWS LETTER 



BIOCHEMICAL CHART FOR ENTERICS 













SHIGELLA 




SALMO- 
NELLA 


PARACOLO BACTRUM 




PROTEUS 




MEDIUM 


3 
o 
u 

Lii 


Q 
Z 

a 

[I, 

nj 


< 
< 

o 

-J 
u 

< 


< 
-J 

E 

CO 

m 
5 


< M U 


ri 


5 

c 

a 

Q 

< 




3 

> 


< 
Z 

c 

N 

< 


3 

UJ 

X 
H 

=2 


Hi 
U 

z 
w 

a 

> 
c 

— 


< 
Z 

< 
X 


■~r. 

2 
< 

O 
u 

> 


to 

J 

PQ 

< 


Z 

< 

a 
o 
S 


ei 

Hi 

a 


K SLANT 


A 


A 


A 


A 


Neg Neg Neg 


Neg 


Neg 


Neg 


Neg 


Neg 


Neg 


Neg 


Neg 


Neg 


Neg 
AG 
Pos 


Neg 
AG 

Neg 


Neg 


1 BUTT 


AG 


AG 


AG 


A(G)* 


AAA 


A 


A 


AG 


A 


A-AG 


A-AG 


A-AG 


A-AG 


AG 

Pos* 


A 


A H2S 


Neg 


Pos 


Neg 


Neg 


Neg Neg Neg 


Neg 


Neg 


Pos* 


Pos 


Pos 


Pos 


Neg 


V 


Neg 


MOTILITY 


Pos* 


Pos* 


Pos* 


Neg 


Neg Neg Neg 


Neg 


Neg 


Pos 


Pos 


Pos 


Pos 


Pos 


V 


Pos 


Pos 


Pos 


Pos 


CITRATE 


Neg* 


Pos 


Pos 


Pos 


Neg Neg Neg 


Neg 


Neg 


Pos* 


Pos* 


Pos 


Pos 


Pos 
Pos 

Neg 


Pos 

Neg 
Neg 


Neg* 
Pos 
Pos 
AG 
Neg 
AG 


Pos* 

Neg 

Pos 

AG 

Neg 

AG 


Neg 
Pos 
Pos 
AG 

Neg 

Neg* 


Pus 


INDOL 


Pos* 


Neg* 


V 


Neg 


V V V 


Neg 


Pos 


Neg 


Neg 


Neg 


Neg 


Pos 


UREA 


Neg 


Neg 


Neg 


Pos 1 - 


Neg Neg Neg 


Neg 


Neg 


Neg 


Neg 


Neg 


Neg 


Pos 


GLUCOSE 


AG 


AG 


AG 


A(G)* 


AAA 


A 


A 


AG 


A 


A AG 
A-AG L 


A-AG 

Neg*'- 


A-AG A-AG 

Neg* Neg 
V A-AG 


A 


LACTOSE 


AG 


AG 


AG 


A(G)* 


Neg Neg Neg 


V 


A* 


Neg 


Neg 


Neg 


SUCROSE 


V 
AG 


V 
AG 


AG 
AG 


A(G)* 
A(G)* 


Neg Neg Neg Neg* 
Neg A* A A 


V 


Neg 


Neg 


V 


A-AG L 


,-V 


MANITOL 


A 


AG 


A 

A'-* 


A-AG 


A-AG 


Neg* 


A-AG 


Neg 


Neg 


Neg 


A 


DULCITOL 


V 


V 


V 


V 


Neg Neg Neg 


Neg 


V 


AG* 


Neg 


V 


Neg 


Neg 


Neg 


Neg 


Neg 


Neg 


SAL1CIN 


V 


V 


AG 


A(G)* 


Neg Neg Neg 


Neg 


Neg 


Neg 


Neg 


V 


Neg* 


V 


A-AG 


AG* 


Neg :i 


Neg 


A* 


KCN 


Neg 


Pos 


Pos 


Pos 


Neg Neg Neg 


Neg 


Neg 


Neg 


Neg Neg 
V=variable 


Pos 
L 


Pos Pos 
= late — 48 his 


Pos Pos 
to 10 days 


Pos 


Pos 


Legend: Neg*=usually negative 

A(G)* = u.sually acid plus gas 


Pos* = usually 
always acid. 


positive 

FIGURE 2 





SHIGELLOSIS 

Shigella bacilli are gram negative, aerobic, non- 
motile, non-sporulating rods. As with the Salmonella 
species, the Shigella suspected specimens should be inoc- 
ulated into the same media as described under "Labor- 
atory Procedure for Isolating Enterics". The Shigella 
group ferments dextrose with acid production, but very 
rarely produces gas. Salicin and dulcitol are not fer- 
mented and citrate is not utilized. Urea is not hydrolized 
and hydrogen sulfide is not produced. Indol may or 
may not be produced. Nitrates are reduced to nitrites. 

The organism Shigella is limited to an inflammatory 
process that involves the large bowel and occasionally, 
the terminal ileum. Acute ulceration and hemorrhage 
of the bowel wall may occur in severe cases. Bloody 
stool specimens are usually obtained in these cases, also. 
Fever results from the absorption of toxic products from 
the gut." 

Patients who recover from Shigella may become 
chronic or intermittent carriers, and those individuals 
with occult infections and sub-clinical symptoms consti- 
tute a major problem in the control of the disease. 

The genus Shigella is divided into four primary 
groups, i.e. A, B, C, and D. These correspond respec- 
tively with S. dysenteriae, S. ftexneri, S. hoydii, and S. 
sonnet. 

Serologic identification can be made by testing the 
dominating somatic factors based on biochemical as 
well as serological differences. The organisms may be 



broken down into many sub-groups based largely on 
antigenic patterns. All of the Shigella groups are patho- 
genic for man and there is no other recognized animal 
host. 

Station Hospital Laboratory, Kenitra, Morocco is 
using Shigella and Salmonella typing and grouping sera 
obtained by the Navy through the Federal Stock Cata- 
log. Note: {For carbohydrate reaction see chart en- 
titled Biochemical Chart for Enterics). Variations of 
the carbohydrate reaction are described by Edwards and 
Ewing.' 

REMARKS 

Identification of Shigella and Salmonella serotypes, 
because they require a large number of single factor 
typing serums, can seldom be done in a small laboratory 
or outside a specialized unit. 

Due to the widespread distribution of Salmonella 
bacilli in many animals and the many avenues for their 
dissemination to man, it can be accepted that multiple 
infections by these organisms have occurred in the pa- 
tients seen and treated at this medical facility. The 
knowledge of the occurrence of these organisms in 
animals, in animal products, and in commercial food 
preparations is vital to the control of the disease. 

Studies have been made of the role played by the 
liver in filtering intestinal bacteria from the blood. Not 
infrequently, Salmonella have been reported isolated 
from patients having liver damage. It may well be that 
this bacillus is the etiological agent in many cases of 



JO 



U.S. NAVY MEDICAL NEWS LETTER 



so-called viral hepatitis seen by the physicians at this 
hospital. 

Salmonella and Shigella organisms may be described 
as exhibiting the attributes of the perfect parasite in that 
they guarantee their own survival and propagation with- 
out killing the host. The organisms appear to be ade- 
quately deployed against man's medical and culinary 
processes, perpetuating their superior role in the co- 
existence they enjoy with the animal kingdom." 

Many cases of enteric infections seen at the Station 
Hospital could probably have been traced to carriers 
and undiagnosed cases of the diseases. Another factor 
which undoubtedly contributed to the increased inci- 
dence of diarrheal diseases during the winter of 1962- 
63, was the abnormal amount of rainfall which resulted 



in the Sebou River flooding rather large areas around 
Kenitra. 

This account of the occurrence of diarrheal diseases 
in the military and dependent population of an overseas 
Naval Activity is presented in the hope that Medical 
Department personnel will be made more aware of cer- 
tain problems with which they may be confronted on 
assignment to overseas duty. 

References 

1. P. R. Edwards and W. H. Ewing, Identification of Enterobac- 
teriaceae. P. 1. Coypright 1955, 

2. Paul H. Black MD, Lawrence J. King PhD, and Morton N. 
Swartz MD, Salmonellosis — A review of some unusual aspects. 
N Eng J Med 262(18) :921-926, May 5, I960. 

3. Bacteriology Manual, U.S. Naval Medical School, NNMC, Be- 
thesda, Md. (1961 Edition) 

4. Control of Communicable Diseases in Man. Pgs. 162-164, 9th 
Edition, 1960. 



TELEVISION VIEWING 

New York( N. Y. (NAVNEWS) — Two Pediatricians 
with the Air Force Medical Corps have contributed a 
new dimension to the discussion about television's harm- 
ful effect on children when it is viewed excessively. The 
standard response of many broadcasters to studies indi- 
cating that moppets spend inordinate blocks of time in 
front of the small screen has been advice to parents. 
"Regulate your child's viewing," the broadcasters have 
in effect urged. "Select his programs, discriminate. The 
responsibility is yours." 

It appears now that certain parents are unable to 
regulate their own television habits and that this weak- 
ness is directly responsible for illness in their children. 
Captains Richard M. Narkewicz and Stanley N. Graven 
reported recently on the "tired-child syndrome" which 
they found among 30 children brought to hospitals at 
Lackland Air Force Base in Texas and Fairchild Air 
Force Base near Spokane, Washington. The children 
ranged in age from three to 12 years. They exhibited 
symptoms of anxiety conditions: chronic fatigue, loss 
of appetite, headache, and vomiting. The parents made 
no mention of their children's television habits, but 
after questioning the families the pediatricians discov- 
ered that the patients were spending an average of 
three to six hours in front of television screens on week- 
days and six to 10 hours on Saturdays and Sundays. 

The parents were told to stop their children's tele- 
vision viewing completely. In 12 of the 30 cases in 
which the instructions were fully followed, the symp- 
toms vanished within two to three weeks. The other 18 
children were allowed to watch television as much as 
two hours a day, and they were free of symptoms in 
three to six weeks. The doctors followed up the families, 
however, and found, in some cases that the children 
were again suffering from severe symptoms of the 
"tired-child syndrome." Once again they were watching 
television excessively. Their parents, particularly the 
fathers, were unwilling to forego evenings in front of 



the television, and the children were caught up in the 
viewing vortex. 

Appeals to parents who are capable of disciplining 
themselves may be effective when they are asked to 
regulate their children's viewing. But what is to be 
done with parents who are themselves television addicts? 
—(Saturday Review)— NAVNEWS, January 1, 1965. 

COCKROACH — OLD AND TOUGH 

Before you grind that next cockroach under your 
heel, spare a thought for this remarkable little fellow 
who has outlived even the dinosaurs. Of all creatures 
who lived 200,000,000 years ago, only the cockroach 
has survived virtually unchanged. 

Although his favorite food is beer, he will eat any- 
thing — hair brushes, shoe polish, paper, rags or asprin. 
And if he has to, he can go for 76 days with no food at 
all. Besides that, if he loses a leg or a nose, he grows a 
new one. 

All of which doesn't make him one bit more lovable. 
—"Gator" Scope, USNH, Jax, Fla., 3(11): 2, Oct. 28, 
1964. 

TEACHING OF PREVENTIVE MEDICINE IN EUROPE 

Progress in the teaching of the preventive aspects of 
medicine in European medical schools over the past 
10-15 years was discussed at a Symposium held from 
22 to 30 July 1964 in Nancy, France, by the WHO 
Regional Office for Europe. The aims and scope of 
such teaching were reviewed, together with ways and 
means of improving it. 

Specific topics included: the teaching of preventive 
medicine in connection with the preclinical and clinical 
sciences, pathology, microbiology, and psychology; the 
place of statistics and epidemiology in such teaching; 
and the role of special chairs of preventive and social 
medicine. 

The Symposium was attended by some 30 participants 
from countries in the European Region, and by repre- 
sentatives of several international organizations. — WHO 
Chronicle 18(8): 311, August 1964. 



U.S. NAVY MEDICAL NEWS LETTER 



11 



FROM THE NOTE BOOK 



LIMITED DUTY RECOMMENDATIONS BY 
BOARDS OF MEDICAL SURVEY 

The purpose of returning a member to a period of 
physically limited duty is to afford the member sufficient 
time to convalesce from a serious illness or injury with 
the expectation that — at the end of the period of limited 
duty — the member can be restored to a full duty status. 
In most cases, BuMed considers that the recommended 
limited duty period should not exceed six months and it 
is only in exceptional circumstances that BuMed will 
concur in a board of medical survey recommendation 
for a period greater than six months. (Exceptions would 
be cases involving tuberculosis and certain special study 
cases) . 

Whenever an enlisted member appears before a board 
of medical survey and the board recommends return to 
limited duty, the member is immediately reported as 
available for assignment to the appropriate Enlisted 
Personnel Distribution Office (EPDO) as prescribed in 
para. 21,72c Enlisted Transfer Manual. If the board's 
recommendation is for limited duty of six months or 
less, the EPDO normally assigns the member to an 
activity near the place of hospitalization in a temporary 
duty status and if necessary in excess of the activity's 
authorized allowance. In such cases, travel costs are 
minimal. However, if the board's recommendation is 
for limited duty in excess of six months, the EPDO 
must issue permanent-change-of-station orders and the 
member must be assigned within an activity's authorized 
allowance. If an authorized allowance billet is not avail- 
able at an activity near the place of hospitalization, the 
member must be ordered elsewhere — perhaps to a far 
distant activity and at considerable expense to the Gov- 
ernment for the member's travel, for his dependents' 
travel, and for the dislocation allowance payment. But 
the need for permanent change of station orders with 
attendant travel and dislocation costs exists only when 
the board of medical survey recommends limited duty in 
excess of six months. If BuMed should later modify the 
board's recommendation to provide for limited duty of 
six months or less, the transfer action-in-retrospect- 
appears unwarranted and wasteful. 

In summary it appears most desirable that — except 
under very exceptional circumstances — boards of medi- 
cal survey should not recommend assignment to limited 
duty for periods in excess of six months. However, at 



the end of the six month period and following adequate 
re-evaluation, the Board of Medical Survey may recom- 
mend an additional period of limited duty, if such 
appears necessary and appropriate. 
— From: Physical Qualifications and Medical Records 
Division, BUMED. 

YOUR WILL 

By R. W. Andre ADJC 

Norfolk, Va. (NAVNEWS), 1 Feb 1965 . . . Some 
people fail to execute a will while others, at one time or 
another, have good intentions but fail to carry them 
out. Only a few are ready for the unexpected. The 
below information reflects what may happen if you do 
not leave a valid will: 

1 . Your family may find itself unnecessarily involved ■ 
in certain court procedures. 

2. Your knowledge of the property you own and 
your advice as to its disposition cannot be passed on for 
it dies with you. 

3. You lose the privilege of naming your executor 
and this may be a costly loss. 

4. You lose the privilege, afforded by laws in most 
states, of naming a guardian for your minor children. 
This is vital, particularly if your wife should not survive 
you. 

5. In some instances, if there is no immediate family, 
your failure to leave a will may result in the passage of 
your property to persons in whom you have no particu- 
lar interest; or even in its escheat (transfer) to the state. 

6. Settling your estate is likely to be more compli- 
cated and may prove more costly. 

7. You lose the opportunity to minimize estate and 
inheritance taxes. This can often be done by a planned 
will. 

In contrast, a will gives you the advantage of specifying: 
To whom your property should go. When it should 
go. In what amounts it should go. How it should be 
safeguarded. By whom it should be handled. 

The Executor: The executor is a person or qualified 
corporate judiciary (bank or trust company) you name 
in your will to settle your estate after you have gone. 
Choose your executor carefully, not on the basis of 
friendship or relationship alone, but on the basis of 
competence and ability to handle money matters. 



12 



U.S. NAVY MEDICAL NEWS LETTER 



Remember: If you die and leave no will, you are 
said to have died "intestate". In effect, the state in 
which you live makes your will for you. Your property 
is distributed in accordance with fixed provisions of the 
state law. No matter how small or large your estate, 
not leaving a will may cause much trouble and incon- 
venience for your survivors. If the husband dies, the 
wife, under the laws of many states, will receive only 
one-third of the husband's estate if there is no will. The 
children in this case, inherit two-thirds and if they are 
minors, a guardian will have to be appointed by the 
probate or surrogated court. In all likelihood, the wife 
will be named that guardian; yet, she will be anything 



but a free agent in handling of the children's money. 
She will have to provide a bond, be under constant 
supervision of the court, and file accountings period- 
ically. Guardianship is generally an expensive and 
cumbersome procedure and can be avoided by a prop- 
erly drawn will. 

Be sure your estate will be handled as you wish — see 
your attorney or Legal Assistance Officer as your legal 
advisor and consultant when taking care of such im- 
portant matters. (It is also highly important that your 
wife have an up-to-date and valid will). 

Once establishing a will, it is important to review and 
update the vital document at regular intervals. 



POSTGRADUATE SHORT COURSES FOR MEDICAL DEPARTMENT 
OFFICERS SPONSORED BY THE DEPARTMENT OF THE ARMY 

DURING FY 1965 

CHANGE IN SCHEDULE 



Course 



Installation 



Date 



Walter Reed General Hospital 
Otolaryngology Basic Science 
Surgical Nursing Course 



Armed Forces Institute of Pathology 
Washington, D. C. 
Walter Reed Army Institute 
of Research 



5 Apr - 28 May 

1965 
29 Mar - 2 Apr 

1965 



This article supersedes announcement in Medical News Letter 44(8), 23 October 1964. 
sional Division, BUMED. 



-Training Branch, Profes- 



OAK KNOLL CONDUCTS CHILDREN'S 
PREVENTIVE DENTAL HEALTH PROGRAM 

In observance of the Seventeenth National Children's 
Dental Health Week 7-13 February, the Dental Service 
at U.S. Naval Hospital, Oakland, conducted a pre- 
ventive dental health program during the month of 
February. 

Oak Knoll military staff children from 4 to 16 years 
old were considered eligible for the program, which 
included bite-wing x-rays, clinical examination, oral 
hygiene instructions, cleaning and polishing of teeth, 
and surface application of stannous fluoride to prevent 
decay. The fluoride treatment was given only with 
parental permission. 

Parents were told just what treatment their children 
required and were given information concerning proper 
care of their children's teeth. 

Each child received a tooth-brushing kit — provided 
through funds contributed by the Oak Knoll Officers' 
Wives Club.— Submitted by RADM Harold J. Cokely 
MC USN, Commanding Officer, U.S. Naval Hospital, 
Oakland, California and DMO, 12th Naval District, 
San Francisco, California. 



SURGEON GENERAL ASKS FOR MAXIMUM 

SUPPORT OF SECNAV TASK FORCE 

BY MEDICAL DEPARTMENT 

On 22 December 1964 the Secretary of the Navy 
directed the establishment of a Task Force to identify 
and examine major factors bearing on personnel reten- 
tion in the Naval Service. The Bureau of Medicine and 
Surgery is represented on this Task Force and it is the 
desire of the Surgeon General to provide maximum 
support through our representative to the total effort of 
the Task Force and therefore in turn to provide maxi- 
mum assistance to the Secretary of the Navy in attempt- 
ing to solve the Navy's personnel retention problems. 

Comments, suggestions and any pertinent information 
which relates in any way with the identification of major 
factors which have potential for improving retention 
are solicited and should be forwarded to: 

SecNav Task Force on Military Personnel Retention 
Room 3732, Arlex 
Navy Department 
Washington, D. C. 20370 
Attn: Medical Representative 



It is increasingly recognized that the hospital alone, and particularly the general hospital, cannot provide adequate 
clinical training for the medical student. It is suggested that future physicians would greatly benefit from supple- 
mentary training in health centres and field training areas. — WHO Chronicle 18(11); 423, November 1964. 



U.S. NAVY MEDICAL NEWS LETTER 



13 



DENTAL SECTION 



EXCERPTS FROM THE REPORT OF THE COMMITTEE ON SCIENTIFIC 

INVESTIGATION OF THE AMERICAN 
ACADEMY OF RESTORATIVE DENTISTRY 



Ralph W. Phillips DSc, Chairman, Committee members: Drs. Joseph F. Volker, Arvin 
W . Mann, Clyde H. Schuyler, and Henry M, Tanner. Indiana University, School of 
Dentistry, Indianapolis, Ind., Jour Pros Den 14(3): 554-557, May-June 1964. 



DENTAL CARIES AND RELATED RESEARCH 

Oral Microbiology. Dirksen, Little, and Bibby have 
continued their studies of the pH of carious cavities. 
Previously they have shown that cavities having thick 
layers of decay, and small openings to the surface, had 
low surface pH values. Their observations have been 
extended to include the pH measurements at different 
depths in isolated cavities. A progressive decrease in 
pH between the surface and the bottom layers of the 
cavity has been noted. The average pH of 31 cavity 
bases in this category was 3.88 as contrasted with an 
average surface pH measurement of 4.91. These find- 
ings give strong support to the primary role of bacteri- 
ally-produced acids in the initiation and progression of 
the carious lesion. 

The clinical usefulness of the bacteriologic control in 
endodontic therapy has been questioned by some clini- 
cians. This point has been investigated by Zeldow and 
Ingle. They have studied 89 teeth with single canals 
and nonvital pulps. Twenty-four of these had a nega- 
tive culture, both at the onset of treatment and at the 
time of the root filling. Sixty-seven had a positive final 
culture before filling. Whereas only one failure was 
reported with the former group, seven were noted in 
the latter in a 2-year follow-up study. 

Systemic Factors and Oral Disease. The effect of 
civilization on the incidence of dental caries has been 
vividly illustrated. In Ghana there has been a rapid 
increase in the extent of tooth decay that parallels the 
increased consumption of refined carbohydrates. In 
1950 the sugar confectionery imports to the country 
were 943,785 lbs. in contrast to 1960 when the importa- 
tion of these products was at the level of 5,907,691 lbs. 
The greatest increase in caries incidence has occurred 
in Europeanized coastal cities, and within each specific 
area the incidence of dental caries is greatest in those 
groups having the highest standard of living and the 
best access to and utilization of general health facilities. 
This is presumptive evidence that local rather than 



systemic factors are responsible for the production of 
tooth decay. 

Fluoride and Dental Caries. The ability of several 
oral preparations to limit human tooth decay has been 
reported for the first time. One of these, an acidulated 
fluoride phosphate solution, has been investigated. Ac- 
cording to the investigators, fluoride in acid phosphate 
solution is readily taken up by the surface enamel, and 
the enamel so treated does not etch and is exceedingly 
resistant to acid dissolution. 

The importance of this phenomenon has been demon- 
strated in two clinical studies. One hundred and fifteen 
children who were given a single topical application of 
acid fluoride and phosphate solution each year for 2 
years had 70 per cent fewer carious surfaces than a 
control group of similar size and composition. In the 
second experiment, 77 children had one side of their 
dentition exposed to four topical applications of neutral 
2 per cent sodium fluoride solution with the other half 
having the same number of applications of this solution 
in 0.15 M of orthophosphoric acid. A reduction of more 
than 50 per cent in new carious surfaces was observed 
on the side treated with the phosphate-fluoride solution. 

Taken collectively these data in children are most 
encouraging but need corroboration. The system also 
needs to be tested in adult populations. 

Vo!!;er and Phillips independently have shown that 
silicate cements contain soluble factors, presumably 
fluoride, that may increase the resistance of tooth struc- 
ture to decalcification. In an extension of these investi- 
gations, it has been noted that when freshly mixed sili- 
cate cement is applied to a polished enamel surface, that 
surface is protected against decalcification by acetic 
acid for as long as 4 hours. It is possible that extracts 
of silicates are at least as effective as the acid fluoride 
phosphate solutions of Brudevold in protecting enamel 
from decalcification or in promoting its remineraliza- 
tion. The extracts of silicates normally contain both 
fluoride and phosphate ions in acid solution but other 
trace elements may enhance the protective effects. 



14 



U.S. NAVY MEDICAL NEWS LETTER 



DENTAL MATERIALS 

Cavity Varnishes. It was pointed out in this review 
last year that cavity varnishes have two merits. Since 
the research in 1963 further corroborates those initial 
observations, these salient factors might be re-empha- 
sized. One is that a properly compounded varnish tends 
to minimize the leakage that occurs around the restora- 
tion. For example, the amalgam restoration does leak 
rather grossly for the first few days or weeks after in- 
sertion into the cavity. Although, as pointed out earlier, 
the leakage rapidly diminishes with time, the initial 
leakage could well be the cause for occasional postop- 
erative sensitivity. If, however, a cavity varnish is used, 
the early leakage is negligible. Comparable results are 
obtained when a varnish is used with certain other re- 
storative materials. Therefore, when the cavity prepara- 
tion is deep and maximum protection is required, the 
use of a cavity varnish is indicated beneath the amal- 
gam, foil, or silicate restoration. 

There is evidence that zinc phosphate or silicate ce- 
ment may be even more acidic, and remain acidic 
longer, than previously believed. The added insult to 
the dentin and pulp of this irritant can then be a serious 
problem whenever the thickness of dentin between the 
restoration and the pulp is 100 microns or less. The 
cavity varnish, while not totally impermeable, does aid 
appreciably in preventing the acid present in this type of 
cement from penetrating through the thin protective 
layer of dentin. Naturally, in the deep cavity prepara- 
tion, both a varnish and a base should be employed. 

Amalgam. A clinical survey of 1,425 amalgam resto- 
rations has corroborated some of the observations re- 
ported last year: (1) marginal weakness is an inherent 
inadequacy of this type of restoration; (2) coarse-cut 
amalgam alloy particles produce restorations with sur- 
face characteristics inferior to those of fine-cut alloys; 
(3) comparable clinical restorations may be produced 
by either mechanical condensation or by firm hand 
condensation; (4) bulk in itself is not as important a 
factor for clinical success of the amalgam restoration as 
previously assumed; and (5) regardless of whether the 
alloy does or does not contain zinc, a meticulously dry 
field is necessary for success. To be sure, none of these 
observations are particularly astonishing but they do 
represent documented guide lines for the successful use 
of this most common of all restorative materials. 

It is now well established, by both in vitro and in 
vivo investigations, that the clinical integrity of this 
restoration is dependent upon reducing the residual 
mercury content below 55 per cent. When the mercury 
of the restoration exceeds this value, an unusually high 
incidence of marginal breakdown and corrosion will 
result. Thus, emphasis in newer technology lies in the 
direction of developing procedures which will minimize 
and better control the final mercury content. One of 
the approaches is simply to use less mercury in the 
original mix. An original alloy-mercury ratio as low as 
1 : 1 may be used, provided the trituration is thorough, 



that a small condenser is used, and heavy pressure em- 
ployed. Although the strength values are comparable 
to those attained by the conventional 5:8 ratio, some- 
what better reproducibility is obtained. Furthermore, 
and advantageously it seems to this writer, no com- 
promise is permitted in the preparation of the material. 
A pressure and mulling device for mixing the alloy and 
mercury also may be satisfactorily used with most al- 
loys. Again, the merit lies in reducing known variables 
and, in some offices, apparatus such as this may aid in 
standardizing the manipulative procedure. 

Resins. The use of dry heat at elevated temperatures 
for polymerizing acrylic resin jackets has been investi- 
gated. Such a technique has not been shown to improve 
the physical properties. As pointed out by Ryge, the 
superior clinical results attained by those who advocate 
the method may well be explained by the fact that these 
practitioners are highly motivated and meticulously 
carry out cavity design, manipulation, and finishing, 
and emphasize patient education in care of the restora- 
tion. 

A number of types of resins and processing tech- 
niques are employed for the construction of partial or 
complete dentures. Laboratory and clinical studies con- 
tinue to determine the differences in accuracy and di- 
mensional stability of these materials and the processing 
procedures. This year, the literature corroborates pre- 
viously reported data which indicate that no over-all 
superiority may truly be claimed for any one material. 

Miscellaneous. The evidence accumulates that in the 
fused porcelain technique, the bond of the porcelain to 
the gold is a most firm one. Whether the union is a 
true adhesion, or simply the result of van der Waal 
forces, is probably only of academic interest. Suffice it 
to say that the bond is adequate to prevent any leakage 
between the porcelain and gold alloy. Apparently, the 
bond is not substantially increased by roughening of 
the gold casting. The phosphate-bonded investments 
used in the casting of the special alloys employed with 
this technique have now been evaluated. The mold 
must be vented, as these materials are more dense than 
the conventional gypsum-type investments. The invest- 
ments do vary in the range of expansion which may be 
obtained. One of the problems associated with certain 
of the products is a tendency to develop a surface 
roughness on the casting when the special liquid is 
diluted in order to reduce the expansion. 

PERIODONTOLOGY 

Automatic Toothbrushes. Several earlier reports pre- 
sented data showing electric toothbrushes to be more 
effective than their manual counterpart. This conclusion 
is controverted by recent studies of Ash, Rainey, and 
Smith. They compared the effectiveness of the two 
most popular models, the Broxodent and General Elec- 
tric instruments, with the roll method of hand brushing 
using a two-row hard, natural bristle brush. According 
to these investigators their studies were designed to 



U.S. NAVY MEDICAL NEWS LETTER 



15 



avoid the "novelty" effect in using an electric tooth- 
brush. This they believed was comparable to the placebo 
effect. Two groups of patients were studied intensively. 
One used the manual toothbrush for 60 days before 
switching to the electric brush for a comparable period. 
The other group used the reverse order. Mechanical 
and electrical tooth brushing were found to be equally 
effective in prevention of dental plaque and calculus. 
They had similar actions on gingivitis, gingival reces- 
sion, gingival crevice depth, and the periodontal disease 
index. 

OCCLUSION 

Mandibular Movements. Credit for outstanding re- 
search on occlusion should go to Hickey of the Uni- 
versity of Kentucky and Allison, Woelfel, Boucher, and 
Stacy of Ohio State University on their studies on 
mandibular movements in three dimensions. 

They conclude that a different condylar position was 
found for rest position, centric relation, and centric 
occlusion. The condyle could be held in a retruded posi- 
tion as a hinge opening movement was made. However, 
no center of rotation could be found in the region of 
the condyle that would produce an arc similar to the 
arc of movement of the incisor pin. 

A direct lateral movement of the condyle was present 
in voluntary lateral movements of the mandible. This 
lateral movement ranged from 4.0 mm in a maximal 
excursion with no tooth contacts to 0.3 mm during 
tooth contacts of masticatory function. Here it might 
be emphasized that the 0.3 mm of lateral Bennett move- 
ment, while the teeth are in functional contact, is suffi- 
cient as an adjustment of an articulating instrument. 

The condyles and the teeth were in the centric occlu- 
sion position during swallowing. 

The teeth contacted in centric occlusion in seventeen 
of eighteen masticatory strokes. The pathway of the 
mandible was guided for a short distance by the in- 
clined planes of the teeth as they approached centric 
occlusion during mastication. The condyle shifted 
bodily with the slightest opening of the teeth from 
centric occlusion. The variation and amount of move- 
ment of the condyles, even within the range of the 
height of the cusps of the teeth, seem to make a freedom 
of cusp movement in centric occlusion desirable. It 
appears very unlikely that any articulator can duplicate 
condyle movements. Occlusion formulated by the func- 
tionally generated path of the individual patient might 
more accurately satisfy individual characteristics. 

INSTRUMENTATION AND PULP PATHOLOGY 

Pain Control. It has been suggested that the ideal 
way to solve sensitivity of eroded areas of exposed den- 
tin would be a routine of home care. A dentifrice con- 
taining 10 per cent strontium chloride is recommended. 
The dentifrice is nontoxic, nonallergenic, and nonirri- 
tating. It is claimed that the use of this dentifrice pro- 



duced significant improvement in 80 of the 86 patients 
tested. 

Corticosteroids. Mosteller continued his clinical ob- 
servations with the corticosteroids, including limited 
histologic studies. He states that there is good clinical 
evidence that the proper use of certain corticosteroid 
solutions will eliminate or reduce thermal sensitivity in 
most teeth. This clinical effectiveness has been attrib- 
uted to the anti-inflammatory action of the corticoster- 
oid. He has made an effort to evaluate histologically, in 
a limited way, the ability of a prednisolone solution to 
decrease or eliminate pulpal inflammation under deep 
cavity preparations. All of the cavities were filled with 
zinc oxide and eugenol cement. All untreated teeth 
showed marked inflammatory pulpal changes. In gen- 
eral, the severity of the pulpal injury varied directly 
with the depth of the cavity preparation. The teeth 
treated with prednisolone also demonstrated pulpal in- 
flammation, but to a lesser degree. On the basis of these 
few specimens, this prednisolone solution does not ap- 
pear capable of completely eliminating pulpal inflam- 
mation in response to deep cavity preparation. In those 
preparations, a base and varnish would still seem to be 
necessary. More histologic data, done in depth, is 
needed before a true evaluation of this therapeutic agent 
may be made. 

SUMMARY 

Clinical observations, which are meaningful, are de- 
pendent upon a well-controlled dental operation carried 
out in the hands of a meticulous and dedicated profes- 
sional man. Surprisingly, such fertile environments are 
not plentiful. For that reason, laboratory data accumu- 
late without the essential parallel clinical research. 

PRESERVATION OF PULP HEALTH DURING 
COMPLETE COVERAGE PROCEDURES 

M. H. Berman DDS, JADA 70(1): 83-89, Jan 1965. 

This author points out the often neglected fact that 
pathologic changes in the dental pulp can be induced 
by operative dentistry as well as by caries. The meth- 
ods he describes for prevention of such induced pulp 
pathology apply to routine cavity restoration as well as 
complete coverage procedures. Each dentist in general 
practice would be well advised to refresh his knowledge 
by study of this article. 

One might reverse the author's second paragraph by 
pointing out that pulp damage from ill-advised operative 
procedures in routine cavity preparation might initiate 
chronic pulpitis which, in later years, would preclude 
use of that tooth as an abutment for an extensive pros- 
thesis. In using modern high-speed cutting technics, 
use of an adequate air-water spray at the cutting site is 
necessary to control the temperature rise. Histopath- 
ological changes following heat-induced pulpal injury 
are not visible clinically, but the cellular changes which 
do occur subsequently lead to pulpal degradation, endo- 



16 



U.S. NAVY MEDICAL NEWS LETTER 



dontic therapy and, ultimately, extraction. Sedative 
medication of the putp, including use of prednisolone, is 
described. Zinc oxide-eugenol type cements make the 
base of choice for indirect pulp-cappings under amal- 
gam restorations; but a calcium hydroxide barrier is 
necessary under resin or silicate cement restorations. In 
addition, use of a cavity liner to occlude freshly cut 
dentinal tubules is important. The author also discusses 
precautions to be taken with hot compound impressions, 
as well as the problem of the hydraulic pressure gen- 
erated in cementation of full coverage restorations. 

TOPICAL USE OF PREDNISOLONE 
IN PERIODONTICS 

LCDR Geral M. Bowers DC USN and LCDR J. Roy 
Elliott DC USN, Jour Periadont 35(6): 36/486-38/488, 
Nov-Dec 1964. 

One hundred thirty-two teeth were treated for thermal 
and tactile hypersensitivity by topical application of 



prednisolone solution. The solution appeared effective 
in the treatment of sensitivity due to incisal (occlusal) 
fractures, extensive occlusal adjustment or odontoplasty, 
periodontal surgery and post scaling and rootplanning 
procedures. It reduced sensitivity related to gingival re- 
cession but the results were not as dramatic and some 
of the teeth failed to respond or suffered relapse. A 
second application of prednisolone solution in combina- 
tion with desensitizing toothpaste proved helpful in the 
control of persistent cases of hypersensitivity. 

There was no instance of a visible side effect of the 
prednisolone solution. Although no conclusions can be 
based on the findings of this clinical study, the authors 
believe the topical application of prednisolone solution 
will prove to be a simple and yet effective method in 
the control of thermal and tactile hypersensitivity in 
the periodontal patient. 

The original article provides the information con- 
cerning the materials and methods used. 



PERSONNEL AND PROFESSIONAL NOTES 



Dental Officer Presentations. Four dental officers of the 
U.S. Naval Dental School, NNMC, Bethesda, Mary- 
land, made the following presentations: 

CAPT Gordon H. Rovelstad DC USN, served as Chair- 
man of a study group, sponsored by the American Col- 
lege of Dentists, concerned with "Changing the Dentist's 
Image of His Own Profession." The group met 17-20 
January in St. Louis, Missouri. 

On 26 January, CAPT Rovelstad presented a lecture 
entitled "Current Trends in Preventive Dentistry," be- 
fore the Education Department of the New York State 
Association of Supervising Dentists for Schools in Al- 
bany, New York. CAPT Rovelstad also talked on 
"Preventive Dentistry and Children's Dentistry," before 
the Alpha Omega Society on 16 February, in Washing- 
ton, D. C. 

CAPT Frank J. Kratochvil DC USN, lectured on 
"Designing Removable Partial Dentures," before the 
Old Dominion Study Club on 25 January in Arlington, 
Virginia. 

CAPT Theodore R. Hunley DC USN, served as 
Panelist and Essayist before the Chicago Dental Society, 
21-24 February in Chicago, Illinois. The presentation 



was entitled, "Operative Dentistry Supports the Treat- 
ment of Advanced, Periodontal Disease." 

LCDR John S. Lindsay DC USN, gave a Dental Es- 
say entitled, "Emergencies in the Dental Office — Treat- 
ment Phase," before the Commonwealth Study Club on 
4 February in Arlington, Virginia. 

Denial Officer Presides Over Gold Foil Study Club. 
CDR C A. De Laurentis DC USN, was elected Presi- 
dent of the Metcalf Gold Foil Study Club of San Diego, 

California, for the year 1965. 

Dental Officers Attend Meeting at Oiongapo, P.I. Dental 
Society. LT R. L. Wellington Eng DC USNR of the 
Dental Department Subic presented an illustrated slide 
lecture and case study entitled, "Clinical Endodontia 
and Immediate Apicoectomy," before the Oiongapo, 
P.I. Dental Society. Dr. Amado Veloira of Oiongapo is 
the President of the Host society. President of the 
Philippine National Dental Association, Dr. Agaton 
Ursua from Manila attended the meeting. CAPT Rich- 
ard D. Calhoun DC USN, Senior Dental Officer, and 
CAPT George H. Sandman DC USN, with other dental 
officers from NAS, Subic Naval Station were also pres- 
ent. — From: Dental Department News, Naval Station, 
Subic Bay, P.I. 



NEURO-ENDOCRINOLOGY AND REPRODUCTION 

A WHO Scientific Group on Neuro-endocrinology 
and Reproduction in the Human convened in Geneva 
from 8 to 14 September 1964. 

Neuro-endocrinology is a rapidly developing science, 



of particular importance for the understanding of hu- 
man reproduction. The Scientific Group's discussions 
covered normal and abnormal aspects of the physiology 
of reproduction, with special reference to lesions, both 
neoplastic and traumatic. — WHO Chronicle 18(8): 
312. August 1964. 



U.S. NAVY MEDICAL NEWS LETTER 



17 



PREVENTIVE MEDICINE 



TUBERCULOSIS CONTROL IN THE NAVY— ARE WE DOING ENOUGH? 

CAPT Donald C. Kent MC USN, Head, Tuberculosis Service U.S. Naval Hospital, 
St. Albans, New York. 



The Task Force on Tuberculosis Control recently 
submitted to the Surgeon General, U.S. Public Health 
Service, a report which caused the nation to face the 
unpleasant fact that there may be reason for "real con- 
cern over the current degree of effectiveness of tubercu- 
losis control efforts in the United States". New cases of 
tuberculosis had diminished sharply from 1950 to 1960, 
as demonstrated by the following reported cases: 84,304 
in 1953, 67,148 in 1957, and 55,494 in 1960. This 
trend has begun to taper off during the past 3 years, 
with 53,315 cases being reported in 1962, a reduction 
of less than 1% from the 1961 total. A more alarming 
note is found in reports from specific areas, e.g., New 
York City, with a dramatic increase in new case reports 
in 1963. Instead of a leveling off, many areas are noting 
an increase in new cases of tuberculosis; herein lies 
reason for concern. The demand for more effective 
control in the years to come, if real tuberculosis control 
and eradication are to be achieved, has already been 
sounded by the Task Force on Tuberculosis and echoed 
by the Chairman of the House Appropriations Com- 
mittee for the U.S. Department of Health, Education, 
and Welfare. 

Table I shows that U.S. Navy statistics for new cases 
of tuberculosis have followed a similar course, with 

TABLE I 

NEW REPORTED CASES, TUBERCULOSIS, 

ACTIVE, PULMONARY, U.S. NAVY AND 

MARINE CORPS 1953 THROUGH 1960 



YEAR 



MINIMAL 



MODERATE 

ADVANCED 



FAR 
ADVANCED 



TOTAL 



1953 


135 


1954 


111 


1955 


141 


1956 


133 


1957 


87 


1958 


95 


1959 


101 


1960 


101 



183 

153 

149 

133 

107 

70 

75 

68 



63 
50 
35 
28 
24 
23 
15 
17 



381 
314 

325 
294 
218 
188 
191 
186 



gradual reduction in cases reported during the early 
1950s, and a leveling off during the late 1950s. Review 
of these figures also illustrates another fact — approxi- 
mately 50% of cases admitted during the latter years of 
1950 had minimal disease. There were a number of 
factors contributing to this distribution of case severity 
among which, in the Navy, was the emphasis placed on 
early case finding by annual chest X-ray. 

A review of Table 2, tuberculosis admissions by 6- 
month periods, January through June, to the Tubercu- 
losis Service, U.S. Naval Hospital, St. Albans, for the 
years 1960 through 1964, cause real concern regarding 
recent trends in the Navy. The increase in 1963 and 
1964 as compared to 1961 and 1962 is noteworthy, 
since it parallels the previously mentioned statistics for 
similar periods in certain areas of the United States. Of 
great concern is the fact that during 1963 and 1964, 
there was noted a predominance of patients with mod- 
erately advanced tuberculosis over those with minimal 
disease. An explanation for this trend is not readily 
available. It would appear that these cases are seeking 
hospital admission later in the disease process than in 
previous years, certainly just the reverse of what would 

TABLE II 

ADMISSIONS, NEW REPORTED CASES OF TU- 
BERCULOSIS FOR SIX-MONTH PERIODS, 1 
JANUARY TO 30 JUNE, 1960 THROUGH 1964 BY 
THE TUBERCULOSIS SERVICE, U.S. NAVAL 
HOSPITAL, ST. ALBANS, NEW YORK 



SEVERITY 

OF 
DISEASE 



1960 1961 1962 1963 1964 



Minimal 
Moderately 
Advanced 
Far 

Advanced 
Miliary 



36 23 

13 7 

13 16 



25 
9 
6 



32 


25 


30 


32 


4 
1 


9 

2 



Total 



904 



938 



255 



2,097 Total 



62 



46 



40 



67 



68 



18 



U.S. NAVY MEDICAL NEWS LETTER 



be anticipated if our tuberculosis control program was 
being properly executed. 

A review of selected case reports from the wards of 
the U.S. Naval Hospital, St. Albans, brings into sharper 
focus certain aspects of the tuberculosis control program 
which have been mishandled. The tuberculosis control 
program as now in operation, in conformance with cur- 
rent instructions of the Bureau of Medicine and Sur- 
gery, if properly implemented, contains the essentials of 
a control program similar to that outlined in the pre- 
viously mentioned Task Force report. Only with com- 
plete implementation by all personnel can it be expected 
to yield the anticipated and desired results. 

CASE REPORTS 

J.M.L, a 23-year old PvtJ USMCR, was first admitted 
to the sick list in October 1963 when an abnormal 
chest film was noted upon arrival for recruit training at 
a marine corps recruit depot. Evaluation revealed a 
cystic lesion in the right upper lobe, and a sputum speci- 
men was positive on culture for Mycobacterium tuber- 
culosis. 

He had enlisted in the Marine Corps in August 1963, 
and a chest X-ray taken at that time was reported to be 
negative. When reviewed, however, the cavitary lesion 
was present at the time of enlistment. 

Antituberculous chemotherapy was given; he was 
discharged from the Naval service, and admitted to a 
civilian sanitarium near his home for continuation of 
the therapy. Upon his admission to the sick list, an 
epidemiology report was filed so that appropriate con- 
tact studies could be instituted. 

Comment: Special attention is required for evalua- 
tion of chest films on enlistment. An incorrect inter- 
pretation leads to a multitude of problems not only 
administrative problems relative to medical discharge, 
but also to being in contact with a large number of 
personnel during recruit training. The problem of con- 
tact investigation and evaluation of a recruit company 
after the completion of their training and transfer to 
new activities can lead to logistic problems of an almost 
insurmountable degree. 

W.T.G. is a 36-year old Sgt./USMC. He was ad- 
mitted to the Naval Tuberculosis Treatment Center 
with a history of documented PPD conversion and an 
abnormal chest X-ray. He had been stationed at the 
same marine corps recruit training depot as J.M.L. 
After contact with J.M.L. was reported, a PPD was 
done in September 1963 which was reported as negative. 
A chest X-ray was not done at that time, however, he 
had had a chest film taken in August 1963. This was 
reported as negative; on re-evaluation, though, this film 
revealed an infiltrate in the left upper lobe. 

After the negative PPD in September 1963 no fur- 
ther tuberculin skin tests were performed, in spite of a 
notation in the Health record stating that this was to 
have been done in November and December 1963 and 
March and September 1964. He was admitted to a 



naval hospital ir May 1964 for evaluation of a duodenal 
ulcer, and a chest X-ray taken during his initial workup 
revealed the presence of an infiltrate in the left apex. 
The PPD at this time was positive with 20 mm indura- 
tion; a sputum was positive on smears for acid fast 
bacilli. 

Comment: Contact with a recruit, not necessarily 
J.M.L. during his training was probably the source of 
this patient's tuberculosis. Contact studies were insti- 
tuted as a result of contact with J.M.L. but were never 
completed since only the one PPD (September 1963) 
was done. Completion of the study at the 3, 6, 9, and 
12-month periods possibly would have allowed earlier 
diagnosis of his conversion, and possibly by INH chem- 
oprophylaxis active disease could have been prevented; 
this is at least the aim of such a program. That a sig- 
nificant degree of protection is provided by INH 
prophylaxis now seems well documented. More com- 
plete followup of the contact studies is necessary in the 
operational Navy, as shown by this and other records. 

K.R.C., a 24-year old EM3/USN , reported aboard 
a carrier in December 1961, and while aboard the ship, 
he was a contact of an active case of tuberculosis. This 
contact occurred at a time when a number of cases of 
tuberculosis were being found aboard this ship. He had 
had a negative PPD and normal chest X-ray when in 
recruit training in I960. On the report of the contact, 
a PPD was accomplished in June 1963, and was re- 
ported to be negative; repeated negative PPDs were 
noted in July and October 1963. A PPD was reported 
to be positive in February 1964; a chest film was taken 
and was essentially negative. No bacteriological studies 
were done and no INH chemoprophylaxis was insti- 
tuted in spite of the documented conversion. A chest 
X-ray was repeated again in April 1964 and was re- 
ported to be abnormal. INH therapy was instituted in 
May 1964, however, no entry was made in the health 
record of this fact. He was finally transferred to a naval 
hospital in mid-May 1964 when a nodular infiltrate with 
central cavitation was noted in the left upper lobe. 
Review of his history at that time revealed that he had 
noted fatigue, anorexia, night sweats, and a 23-pound 
weight loss since March 1964. In spite of these symp- 
toms and the documented PPD conversion, even on a 
ship with a known full-brown tuberculosis epidemic, no 
further workup was instituted nor was INH chemo- 
prophylaxis instituted until after the parenchymal in- 
filtrate became evident. 

Comment: Proper studies were accomplished on the 
man, with PPD being done at the designated times, 
however, when conversion was discovered, no bacteri- 
ological studies were accomplished, and no INH pro- 
phylaxis was offered to the man. It was not until after 
an abnormal chest film was noted (2 months after docu- 
mented conversion) that INH chemoprophylaxis was 
ordered. The fact of such therapy was never noted in 
the health record for later medical officers to observe; 
the history of treatment was obtained from the patient. 



U.S. NAVY MEDICAL NEWS LETTER 



19 



This occurred on a naval ship during a tuberculosis 
epidemic, the first case of which was another docu- 
mented convertor not given the advantage of INH 
chemoprophylaxis, 

R.P.O., a 23-year old Pvt./USMC, was being exam- 
ined prior to leaving for a tour of duty in the Mediter- 
ranean in April 1963. A PPD was noted to be markedly 
positive. A PPD done in April 1962 was reported to 
have been negative. In the interim, he had been in 
contact with a marine with active tuberculosis, how- 
ever, no contact study was done. At the time of the 
positive PPD, a chest X-ray was reported to be abnor- 
mal, however, later review of this film revealed it to 
have a negative film, the abnormality was in truth an 
artefact. He gave a history of hemoptysis and of a 
12-pound weight loss; smears of sputum were negative 
for acid fast bacilli. In spite of the PPD conversion, 
and what was felt to have been an abnormal chest film, 
and the presence of symptoms, he was allowed to con- 
tinue on duty (!) and was transferred to the Mediter- 
ranean with a marine unit. INH chemoprophylaxis was 
never instituted. Shortly after arrival in the oversea area 
a culture of sputum obtained at the time of evaluation 
was reported as positive for Mycobacterium tubercu- 
losis. 

He was transferred to a tuberculosis treatment center. 
Evaluation revealed no evidence for endobronchial 
disease; chest X-rays were all negative. Because of the 
documented PPD conversion and the positive culture, 
antituberculous chemotherapy in conventional manner 
was instituted. 

Comment: There is a misapprehension among many 
medical personnel that primary tuberculosis (mani- 
fested by PPD conversion) is a completely innocuous 
condition, not attendant by any problem of contagion. 
That this is not always true is indicated in the case of 
R.P.O., who was found to have a positive culture of 
Mycobacterium tuberculosis, in spite of his negative 
chest film. That he was contagious, at least to a degree, 
at the time of sputum culture cannot be disputed. It has 
been well-documented in the past that positive cultures 
at the time of conversion are not a rarity: 40% of one 
series of recent converters were found to be positive, 
50% of another. 

R.P.O. is not an isolated case; a series of such cases 
with documented PPD conversion, negative chest film, 
and positive culture have been seen and evaluated at the 
two Naval Tuberculosis Treatment Facilities. Because 
of this fact, bacteriological studies are imperative in all 
converters, including bacteriologic cultures of specimens 
of sputum or gastric contents. Such converters may be 
possible sources of further dissemination of disease. 
Outbreaks of tuberculosis can be contained only by 
identifying all sources of contagion. 

Other failures are evident in the case of R.P.O. INH 
prophylaxis was not instituted even with documentated 
PPD conversion. Contact studies had never been insti- 



tuted in spite of his tuberculosis contact. Last, but not 
least, in spite of the conversion, abnormal chest film 
interpretation and history of contact with an active 
tuberculosis case, he was allowed to be transferred over- 
seas with a troop shipment. The explanation for this 
last sin of commission may lie under the heading of 
APATHY or INERTIA on the part of medical depart- 
ment personnel. 

This is not an isolated instance of incomplete evalua- 
tion of contacts, by improper followup, failure to in- 
clude bacteriologic studies of all convertors and failure 
to institute INH prophylaxis. These facets of tubercu- 
losis control do not require hospitals for their execution 
— these are failures in the field at the time and place 
where control efforts can be maximally effective. 

P.E.M., a 22-year old HN/USN, was noted to be a 
PPD convertor in August 1962. During the preceding 
nine months he had worked on the contagion ward of a 
naval hospital. He was carefully evaluated at that ac- 
tivity, chest X-rays were negative, and sputum and 
gastric cultures were negative on culture for M. tuber- 
culosis. He was started on INH 100 mgm t.i.d; and 
followed in accordance with Bureau of Medicine and 
Surgery instructions at quarterly intervals; a chest film 
in October 1962 was normal. A repeated chest film in 
January 1963 revealed a left upper lobe infiltrate. Upon 
questioning, the HN claimed that he had faithfully 
taken his INH in the prescribed dosage. 

Further evaluation at a naval tuberculosis treatment 
facility revealed that the apical infiltrate had developed 
a central cavity, and sputum and gastric cultures were 
negative for M. tuberculosis. PAS was added to the 
regimen. In spite of continuation of therapy, the cavity 
did not close, and after six months of therapy a thick 
walled cavity was resected, along with apical posterior 
and anterior segment of the left upper lobe. Tissue 
smears were positive for acid fast bacilli; tissue cultures 
were negative. 

Comment: It must be pointed out that in spite of 
every effort to do a proper workup, institution of INH 
chemoprophylaxis will be a failure in a certain number 
of cases with a developing active lesion. However, such 
a failure does not disprove the effectiveness of chemo- 
prophylaxis but merely underscores the necessity of 
careful followup of all those individuals on the pro- 
phylaxis program to prevent such a development. 

This case emphasizes an additional point, the neces- 
sity for the medical officer to ensure that patients started 
on the INH program are taking their therapy regularly 
and in the recommended dose. This corpsman swore 
he had taken his treatment, but in many cases a history 
of intermittent or haphazard prophylaxis may be ob- 
tained. Statistics are available which demonstrate that 
of such a group, 15% never commence their treatment, 
38% never complete the treatment for the twelve 
months, and of the remainder 47% of those completing 
the treatment, have not taken the dose regularly. These 
figures emphasize the necessity of properly indoctrinat- 



20 



U.S. NAVY MEDICAL NEWS LETTER 



ing converters in regard to the implications of a positive 
tuberculin reaction and the need for prophylaxis and 
followup throughout the treatment year and for a total 
of at least five years. 

T.L.H., a 20-year old DKSN/USN, was admitted for 
evaluation of an abnormal infiltrate in his left upper 
lobe noted at the time of a chest film screening because 
of a tuberculosis epidemic aboard his ship. He was a 
shipmate of K.R.C., previously reported. Review of his 
health record revealed that he had been on active duty 
since 1962, but had had no PPD accomplished on entry 
on active duty since he was a reservist who had not been 
given recruit training at a naval recruit training center. 
He stated that he had had a PPD done in 1963 after a 
tuberculosis contact. This was not recorded in the health 
record, and no further studies were accomplished. At 
the time of admission, he had an apical infiltrate, a 
positive PPD, and probably recently acquired tubercu- 
losis from aboard his ship. The time of conversion could 
not be documented since no records of previous PPD 
were in his health record. 

Comment: This USNR member is one of many proc- 
essed through the treatment centers who have missed 
their initial PPD skin test on entry into active duty. 
Activities processing such individuals must assume re- 
sponsibility for accomplishing the tuberculin skin test. 
Knowledge of previous PPDs is of great clinical im- 
portance in cases such as T.L.H. with a minimal infil- 
trate. The lack of proper entry when the test was ac- 
complished is a gross defect, and this should be cor- 
rected if clinical facilities are to use such health records 
to their utmost advantage. A recent survey of health 
records by the Inspector General, Medical, has revealed 
that less than 50% of health records examined con- 
tained information as to previous PPD studies; each 
activity must ensure that this all important baseline is 
recorded in the health records of their personnel. 

An incorrect or illegible entry is as poor as no entry. 
Activities should assure that PPD entries are complete 
and correct as to type of tuberculin used, degree of re- 
action (induration), and date of administration. Too 
many entries leave questions impossible to answer as to 
test strength used, and the meaning of the reading en- 
tered in the record. Reactions should be read as milli- 
meters of induration, not erythema, and should be exact 
as to number of millimeters, not noted to be one or 
two plus. 

V.D.W., a 56-year old GMGC/USN, was first ad- 
mitted to the sick list in July 1960 because of an ab- 
normal chest roentgenogram. He was first noted to have 
an abnormal chest film in 1950, however, no treatment 
was recommended at that time and in the interim no 
definite followup was carried out. 

Evaluation in 1960 revealed bilateral fibrocalctfic 
nodular densities at both apices, and a gastric culture 
was positive for M. tuberculosis. Treatment with INH 
and PAS was instituted in conventional doses. Sputum 



conversion occurred in one month and followup X-ray 
revealed partial resolution of the infiltrate. He was 
boarded to limited duty in November 1961, and therapy 
was discontinued after 18 months of treatment. After 
re-evaluation in November 1 962, he was returned to 
full duty with no recommendation that followup be 
continued. No tomograms of the chest were obtained 
during his 1962 re-evaluation. 

This man requested a film be taken in October 1963, 
and at that time a cavitary lesion was suspected which 
was confirmed by tomography. A gastric culture was 
positive for M . tuberculosis. 

After appropriate antituberculous chemotherapy, the 
cavitary residual lesion was resected, with an uncom- 
plicated postoperative course. Therapy continues. 

Comment: Several points appear pertinent regarding 
V.D.W. First, an abnormal chest film had been noted 
but inadequately followed for 10 years. At some period 
of time, he developed an active lesion that allowed 
spread of his disease throughout an unknown number of 
contacts for an unknown amount of time prior to its 
discovery. Recommendations of the Arden House 
Group meeting in an effort to develop procedures to 
further tuberculosis eradication, would now include 
prophylactic chemotherapy for such a lesion. This 
recommendation is being applied in many cases such as 
V.D.W. at present, with an aim of wiping out tubercu- 
losis in our population. All abnormal chest X-rays 
should be completely followed up; this must include 
proper bacteriologic studies and comparison with pre- 
vious films. Inactivity or state of arrest cannot be de- 
termined without both stability of X-ray plus negative 
bacteriology. 

The failure to recommend followup on return to full 
duty for V.D.W. and the subsequent course of his di- 
sease demonstrates the necessity for lifetime followup, 
with chest X-rays and bacteriologic studies performed 
at least annually, of all patients having had tuberculosis. 

DISCUSSION 

Review of the above case reports brings into focus 
certain points of the Navy Tuberculosis Control Pro- 
gram that need further and better controlled implemen- 
tation. A well-outlined program is not available in the 
U.S. Navy, and should be familiar to every medical 
officer, whatever his position. Only by conscientious 
effort on the part of all Medical department personnel 
can it be expected to result in reduction and control of 
tuberculosis in the naval service. The fact that the 
statistical trend shows a persistently increasing problem 
of tuberculosis, and the fact that epidemics continue to 
occur in naval shore activities and aboard ships must 
direct our attention toward the need for more complete 
and more effective implementation of the tuberculosis 
control program. All medical officers must regard this 
as their personal responsibility to assure that all aspects 
of the tuberculosis control directives, promulgated by 
the Bureau of Medicine and Surgery, be completely and 



U.S. NAVY MEDICAL NEWS LETTER 



21 



effectively implemented. APATHY toward tuberculosis 
and tuberculosis control must not be allowed to develop, 
for apathy and control of the disease are mutually 
exclusive. 

A STATE OF APATHY? 

In a recent survey conducted at one of the U.S. Navy 
receiving stations, 50% of the records of personnel re- 
porting for overseas transportation showed one or more 
immunization discrepancies. Forty-two percent of re- 
porting personnel did not have a Department of Defense 
immunization Certificate, DD Form 737, in their pos- 
session or an entry of immunization in their health 
records; in the case of civilians or dependents no Inter- 
national Certificates of Vaccination, PHS-731 had been 
prepared. Forty percent required 2 or more immuniza- 
tions. The experience at this station is not unique. The 
situation might be duplicated at almost any Navy or 
Marine Corps activity in the United States. Many indi- 
viduals arriving at points of embarkation for transpor- 
tation by the Military Sea Transport Service (MSTS), 
and Military Air Transport Service (MATS) report 
without required immunizations or records of immuni- 
zation. Other common discrepancies reported are as 
follows: 

a. Date improperly denoted by figures versus three 
letter abbreviation of the month, 

b. Immunization recorded as given earlier than in- 
terval specified for subsequent series. 

c. Smallpox vaccination dated on date given versus 
date read. 

d. No apparent attention when revised instruction is 
issued changing requirement for entry to various geo- 
graphic areas. 

The importance of immunization in military opera- 
tions has been well documented in many wars. In the 
Korean War, for example, there were 50,000 cases of 
smallpox among the South Koreans, while only 30 
cases occurred among all United Nations troops; with- 
out protective vaccination, a military catastrophe might 
have resulted. Yet, despite frequent emphasis of such 
facts, proper immunization is often neglected. 

It is the responsibility of all members of the Medical 
Department to exert a continuing effort to maintain a 
satisfactory immunization status of all personnel under 
their care. The Medical Department of each Naval and 
Marine Corps activity should emphasize the importance 
of completion of and proper recording of all immuniza- 
tions of both military and civilian personnel, including 
dependents, as described in BUMED Instruction 
6230. ID, "Immunization Requirements and Proce- 
dures." A state of apathy must not develop. 

— PrevMedDiv, BUMED 



SYMPOSIUM ON VENEREAL DISEASE 

The University of California at Los Angeles held a 
Symposium on Venereal Disease on 6-7 February 1965 
at the University. Members of the Medical Department 
of the U.S. Navy may obtain a brochure describing the 
program and results of the Symposium by writing to: 

Thomas H. Sternberg, M.D. 

Professor of Dermatology and 

Assistant Dean in Charge of 

Postgraduate Medical Education 

University of California 

Los Angeles, California 

— PrevMedDiv, BUMED 

EARLY DETECTION OF 
PHENY LKETONUR I A 

Phenylketonuria is the result of an inborn error of 
metabolism and usually produces severe and irreversible 
brain damage in young children, requiring in most 
cases life long institutionalization. However, these chil- 
dren are clinically normal at birth, and with early de- 
tection and prompt treatment through the provision of a 
special diet, there is every reason to expect that this 
brain damage can be prevented. Aside from important 
humane considerations, each case detected and cared 
for represents a significant economic saving to the 
country. 

Currently 18 states have laws authorizing their re- 
spective public health departments to implement a 
mandatory phenylketonuria testing program of infants. 
The frequently employed ferric chloride and phenistix 
tests, though acceptable for testing older children, are 
not sufficiently sensitive for screening newborn babies. 
If the condition of phenylketonuria is not detected until 
the child is 1 month of age or older, irreversible brain 
damage will have occurred and treatment may be futile. 
In view of this, the state of Massachusetts has recently 
enacted legislation requiring the testing of every infant 
born in that state by the Guthrie technique. This test, 
also known as the Bacillus Subtilis inhibition test, is 
effective in detecting the condition of phenylketonuria 
in infants under one month of age and is usually per- 
formed on the third to fifth day after birth. The test 
requires only a small amount of venous or capillary 
blood and a heel puncture is a convenient method of 
obtaining the specimen. Since introduction of this test- 
ing program in a state-wide basis in Massachusetts, 
90,000 newborn infants have been screened and 10 
cases of phenylketonuria have been discovered and 
placed on treatment. — Tuberculosis Control Section, 
PrevMed Div, BUMED 



Among the new methods and techniques being tried out for the control of the snail vectors of bilharziasis is 
the use of an electric "barrier" to keep snails from passing given points in a stream. — WHO Chronicle 18(11): 
431, November 1964. 



22 



U.S. NAVY MEDICAL NEWS LETTER 



KNOW YOUR WORLD 



DID YOU KNOW? 

That water was at the roots of the civilizations that 
sprang up on the banks of the rivers Nile, Tigris, 
Euphrates, Indus, Ganges and the Yangtze Kiang? 

People were not then as numerous as they are now; 
they were not increasing at the explosive rate common 
in the second half of the 20th century, their urbaniza- 
tion was not as complex, and the sources of pollution 
were simpler. Today, over 200 million urban people 
do not have access to a water supply that by modern 
standards is safe and ample. ( 1 ) 



least 4 and possibly 6 dengue viruses have been isolated 
together with chikungunya virus in Thailand. (5) 



That water industry in the United States, by weight 
of material handled, is 7 times bigger than all other 
industries put together? 

It takes: 10 liters of water to produce 1 liter of gaso- 
line, 40 liters of water to produce 1 can of vegetables, 
100 liters of water to produce 1 kilogram of paper, 
600 liters of water to produce 1 kilogram of woolen 
cloth, 3,500 liters of water to produce 1 ton of dry 
cement, 20,000 liters of water to produce 1 ton of steel. 
(2) 



That "Skunk Boats" ("Hydrophobia Skunks"), were 
real enough to the Arizona cowhands? 

As late as the roaring twenties, "skunk boats" were 
made to order by the local tent and awning purveyor 
by use of heavy canvas, about 6x3x2 feet, which 
could be folded and carried in a bed-roll or opened, it 
could be staked out held by a stick at each corner with 
the bed-roll thrown in it for sleeping at night. One cow 
puncher put it this way, "I wasn't much put out by 
rattlers, but to be bitten by a hydrophobia skunk, man 
that would be fatal." The skunk boat has joined the 
prairie schooner in limbo. (3) 



That the 1954 epidemic of hemorrhagic fever in 
Manila, Republic of the Philippines, affected mainly 
children? 

Since then, outbreaks have occurred annually, with 
peaks every 4 years, affecting various cities and towns 
in the Philippines, in addition to Manila. In the first 
9 months of 1964, 739 cases were hospitalized in 
Manila. Since 1956, dengue viruses 2, 3, and 4 have 
been isolated from patients. (4) 



That in Bangkok, Thailand, a major epidemic of 
hemorrhagic fever occurred in 1 958, mainly in children. 
Although small epidemics have been reported previously 
since I95S, outbreaks have occurred every year. In the 
first 7 months of 1964, 3,117 cases were hospitalized. 
Fatality rates varied from 4 to 10% in different out- 
breaks. At first, the disease seemed to be restricted to 
urban areas in the central plain and the southeast and 
southwest coasts, however, in 1964 significant outbreaks 
occurred in towns in north and northeast Thailand. At 



That the U.S. Army Medical Research Laboratory at 
Fort Knox, Kentucky, will furnish biochemical and 
pathological assistance to the Government of Costa Rica 
in a research program relating to venomous snake bites? 

The joint study is expected to produce antiserums 
effective against each of the major species of poisonous 
snakes found in Costa Rica; to develop techniques for 
improvement of first aid and hospital treatment of snake 
bites; to evaluate chemical agents such as dihydrolipoic 
acid and tetracycline known to have some detoxifying 
action on snake venoms; and to develop other com- 
pounds for this purpose. 

Venom from about 200 snakes will be used to ven- 
omize horses. Serum collected from the blood will be 
processed by the Biochemistry Department, School of 
Medicine, University of Costa Rica. To produce an 
antiserum, 2 - 4 months will be required. 

New techniques or therapeutic agents to be used will 
be administered only by Costa Rican medical repre- 
sentatives. United States officials will not treat patients. 

On completion of the 1-year program, a trained staff 
of Costa Ricans will continue independent work in the 
anti-snake serum program. (6) 



That apprentices to surgeon-apothecaries were ex- 
pected to maintain a jar of leeches in good fettle, ready 
for emergencies? 

"The leeches were kept in a glass jar topped with 
porous cloth. Periodically, the apprentice rubbed them 
between his palms, half a dozen at a time, in order to 
remove the slime. If, before application, they were 
briskly towelled, they were supposed to suck blood with 
more avidity. Leeches spent long periods of extreme 
hunger and sometimes, despairing of pasturing on a 
poet's brow or a bishop's ankle, they would resort to 
cannibalism. A healthy leech was expected to be able 
to take in V2 ounce of blood before being gorged. The 
charge to the patient was usually sixpence a leech." (7) 

References: 

1. WHO Mag World Health, July-August 1964, p 6. 

2. WHO Mag World Health, July-August 1964, p 
14. 

3. CDC Veterinary Public HIth Notes, DHEW PHS, 
July 1964, p 4. 

4. WHO Wkly Epid. Record, 39:665. 30 Dec 1964. 

5. WHO Wkly Epid. Record, 39:665, 30 Dec 1964. 

6. News Release of the Office of Assistant Secretary 
of Defense (Public Affairs) Washington, D. C, 
22 Dec 1964. 

7. Medical Directors Notebook, Eaton Labs, Aug 
1964, p 6 (E. S. Turner: Call the Doctor, M. 
Joseph, Ltd, London, 1958). 



U.S. NAVY MEDICAL NEWS LETTER 



23 



NAVY EVENTS AT AMERICAN COLLEGE 

OF PHYSICIANS 

MEETING, CHICAGO, ILLINOIS, 

22-26 MARCH 

The Navy will sponsor the annual Tri-Service social 



hour which will take place on Tuesday, 23 March at the 
Waldorf Room, Conrad Hilton Hotel from 6:00 to 8:00 
P.M. All military medical officers attending the con- 
vention are invited. Tickets will be available at the 
military booth at the registration desk. 

—Professional Div, BUMED 



MISCELLANY 



BUMED 6222.9 
BUMED-721 3-TRW:rd 
5 February 1965 

BUMED INSTRUCTION 6222.9 

Subj: Early detection of syphilis in patients with other 
venereal diseases 

1. Purpose. To set forth requirements for examina- 
tions, including followup, of patients who have con- 
tracted nonsyphilitic venereal diseases, in order to detect 
early and unrecognized cases of syphilis, 

2. Action 

a. All Navy and Marine Corps personnel on active 
duty who are diagnosed as having nonsyphilitic venereal 
diseases shall have a serological test for syphilis in 
conjunction with initial treatment, when practicable, and 
at 2, 4, and 6 months after diagnosis. A summary 
statement shall be entered on Standard Form 600, 
Chronological Record of Medical Care, in the Health 
Record, stating serological results. 

b. For purposes of this Instruction, nongonococcic 
urethritis is to be considered a venereal disease. 

c. Incident to receipt or transfer of personnel, annu- 
al verification of Health Record, or any periodic physi- 
cal examination, the member's Health Record shall be 
reviewed and when indicated appropriate followup ac- 
tion instituted as outlined in paragraph 2a above. In alt 
cases where the current Health Record does not show a 
negative serology 6 months or more following estab- 
lishment of diagnosis of nonsyphilitic venereal disease, 
a serology test for syphilis shall be obtained and the 
results recorded on Standard Form 600 in the Health 
Record. 

S/R. B. BROWN 
Acting 

AMERICAN INDUSTRIAL HYGIENE 

CONFERENCE TO CONVENE IN 

HOUSTON, TEXAS 

Noted industrial hygienists from the United States 
and seven foreign nations will present highly technical 



papers May 3-7 during the 26th annual American In- 
dustrial Hygiene Conference in Houston, Texas. 

The conference, cosponsored annually by the Amer- 
ican Industrial Hygiene Association and the American 
Conference of Governmental Industrial Hygienists, will 
feature refresher courses, panel conferences and scien- 
tific exhibits in addition to the many individual papers 
to be presented. 

Topics scheduled for general sessions include aerosol 
technology, analytical chemistry, biochemical essays, 
radiation medicine, engineering, air polution, respira- 
tory protective devices and toxicology. 

GROUP DISCUSSION 
REDUCES ACCIDENT RATES 

That people can talk their way out of accidental in- 
juries, among other things, is indicated in a study spon- 
sored by the Public Health Service, U.S. Department of 
Health, Education, and Welfare. 

The study shows that an organized program of small 
discussion groups at a community level may help to 
reduce hospital admissions for accidental injuries at 
home. The initial findings of the research project were 
announced today by Dr. Paul V. Joliet, Chief of the 
Division of Accident Prevention. 

About 4,000 residents of Roxborough, a part of 
Philadelphia, Pennsylvania, participated in the project 
by meeting in small groups and public meetings to 
discuss accident causation and prevention. Subsequently, 
hospital admissions for accidental injury treatment 
dropped significantly in the Roxborough project area. 

The group discussion experiment was undertaken by 
the Philadelphia Department of Public Health in 1962, 
with the community action phase concentrated in 1963. 

A recently completed tabulation of data for the two 
years indicates that hospital inpatient accidental injury 
cases dropped 17 percent in the study area. In five 
census tracts of the study area, where 85 percent of the 
group discussion meeting activities were concentrated, 
inpatient accidental injury cases decreased 26 percent. 

"The Division of Accident Prevention sponsored this 
work to find out if accidental injuries could be signif- 



24 



U.S. NAVY MEDICAL NEWS LETTER 



icantly reduced by the group discussion technique," 
Dr. Joliet explained. 

"The project results indicate that the method used in 
Roxborough can reduce injuries requiring hospital care. 
We hope to confirm this through additional research. 
More than a quarter of all accidental deaths and about 
19 million disabling injuries occur annually in or 
around homes in the United States. Any plan of action 
that will help to reduce these injuries is important to the 
health and well-being of the people of our country," 
Dr. Joliet said. 

The Roxborough project was among 66 entries sub- 
mitted to the 1964 Metropolitan Life Award Program 
for Research in Accident Prevention. It has been judged 
by the National Safety Council to be one of the 12 best 
in the Nation. 

MR. J. R. BERKSHIRE APPOINTED TO 

AMERICAN PSYCHOLOGICAL ASSOCIATION 

COMMITTEE 

Mr. J. Roger Berkshire, Head, Aviation Psychology 
at the Naval School of Aviation Medicine, has been 
appointed to the Henry A. Imus Awards committee of 
the American Psychological Association. 

The Henry A. Imus Award, which consists of a 
certificate and cash, will be presented to a junior scien- 
tist in the military establishment for outstanding psy- 
chological research and must be below the rank of 
major or lieutenant commander and if a civilian, below 
the Civil Service grade of GS-13. The recipient will be 
presented the Award at the Association's annual meet- 
ing, which will be held September 2-8 in Chicago. 

This award was established by the American Psy- 
chological Association in memory of the late Dr. Henry 
A. Imus who was Deputy and Assistant Director of 
Research at the U.S. Naval School of Aviation Medicine 
until his death in May 1964.— From: P.I.O., U.S. 
Naval Aviation Med Cen, Pensacola, Fla., 8 Feb 1965. 

ANNOUNCEMENT OF 

SECOND ANNUAL ROCKY MOUNTAIN 

BIOENG1NEERING SYMPOSIUM 

This Symposium will be held in Denver, Colorado on 
3 and 4 May, 1965. It is believed that it will be an 
even greater success than the First Symposium. The 



sponsors hereby invite the submission of papers from 
potential contributors. Abstracts of not more than 250 
words should be sent, with a brief biographic sketch, 
and without delay to: 

Major G. J. D. Schock, DFC 

U.S. Air Force Academy, 

Colorado 80840 
As a matter of interest to some of our readers, 
Major Schock holds a Ph.D. degree in Physiology. 

— Editor 

MEASLES VACCINATION ADVISED 

With the advent of the 1965 measles season (Febru- 
ary through April), Surgeon General Luther L. Terry, 
of the Public Health Service, Department of Health, 
Education, and Welfare, said today "that only about 7 
million children have been protected by measles vac- 
cines, leaving about 20 million susceptible children 
unprotected, 

"Measles is so common a childhood disease that 90 
percent of our children get it before their fifteenth 
birthday. Nevertheless, it is not the harmless illness 
that most mothers seem to think it is," Dr. Terry 
warned. 

Although recovery is routine for most children, about 
500 children every year die from illnesses stemming 
from it. These are caused by encephalitis or pneu- 
monia. About one out of every 1,000 cases is followed 
by encephalitis. Fifteen to 20 percent of the enceph- 
alitis cases are left with such after-effects as mental 
retardation, visual or hearing problems, or behavior 
disorders, and about 10 percent of the encephalitis 
cases die. 

"Over 490,000 cases of measles were reported to the 
Public Health Service in 1964, and we suspect that only 
about one-tenth of the actual cases were reported," 
Dr. Terry said. Many cases are not even seen by a 
physician, he explained, because so many parents think 
of it as an "innocent" disease. 

"Fortunately, effective vaccines are now available and 
vaccination can relieve the parents of worry about 
measles and its after-effects. Only a single dose is re- 
quired. In the meantime, any child that develops the 
telltale red splotches should be seen by a physician at 
once," Dr. Terry urged. — USPHS News Release. 



TUBERCULOSIS CONTROL IN PANAMA 

The Government of Panama, with the help of 
UNICEF and the Pan American Sanitary Bureau, which 
acts as the WHO Regional Office for the Americas, is 
to launch a tuberculosis control campaign in four of its 
nine provinces (Code, Herrera, Los Santos, and Ver- 
aguas) which together cover an area of 8,000 square 
miles in the centre of the country. 

It is planned to x-ray and tuberculin-test all of the 



area's 400,000 predominantly rural inhabitants — about 
one-third of Panama's total population. Drug treatment 
will be given to those found to have tuberculosis and 
people in good health will be vaccinated against the 
disease. Tuberculosis has been increasing in the rural 
areas of the country since 1946, following the return of 
many country-dwellers who had worked in Panama 
City, Colon, and other urban centres during the Second 
World War and had contracted the disease there. 
—WHO Chronicle 18(11): 432, November 1964. 



U.S. NAVY MEDICAL NEWS LETTER 



25 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA. MARYLAND 20014 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



OFFICAL BUSINESS 



PERMIT NO. 104S 



U.S. NAVY MEDICAL NEWS LETTER